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DATA PRIVACY ADVISORY <br /> (n acoordance with Minnesota State Statt�te 13.U4 Rights af Subjects of Data, Subcf. 2, 'Tennessen waming",we <br /> would like to inform you that your request for a permit or license from the City o}�rono or any of Its departments <br /> may require you io fumish certain private or confidential iriformation. <br /> You are notfied that; <br /> 1. The iMnrmation you f�mish wili be used to determine your qualificati�on for the permit or license <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit w license. <br /> 3. The irrformation may be shared with ott�er local, state or federal agendes to the exterrt necessary <br /> to process the permit or license. <br /> 4. If your requested permit ar license requFres Coundl acdon to appro�e, some informatior� may <br /> hecome public. <br /> 5. You have certain rights ur►der Minneso#a State Statute 13.04 (see foAowi�g page) to review <br /> private data on yourself. <br /> 6. Your full name is required to process thls appllcatlon or permit <br /> /�r`aha eL G'lfr�7`on �a-�'o�-� <br /> L,i`s Q N��/`e L.a.��sor� <br /> First Middle Last <br /> ���� �'p� �lass �� <br /> Address <br /> �haSlca /%! �'�318' G/z-�70- 9��.3 <br /> City State Zip Phane <br /> I understand my rigFrts as stated above. <br /> �- _ <br /> Signature <br /> RECEIVED <br /> Packef Lest Updeted Januery 2018 <br /> A�'3 AUG "� 9 2015 <br /> � 3 .7 S� c�rr o�oRONo <br />