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QA2ll�PRNACY VISORY <br /> In accordance with Mlnnesota $tate Statute 13.04 Rights of SubJects of Data, St�bd. 2, "Ter�nessen wam9ng',we <br /> would like to inform you tMat your request for a permit or license frorn the Clty of Orona�any of i#s departfnents <br /> rnay r�equ�ire you to fumish certrt�in prNate or cflnfldential Infortnation. <br /> You are rrotified thet: <br /> 1• The ir�formation yrou fumish wlll be used to de�ermine ycwr quali�ca�on for the perm�or lict�xtse <br /> neqtlested• <br /> 2. You may refrise to supply data,but refusel may require th�t the Ciiy deny the permit or IfcBnse. <br /> 3. The informat�on may be shar�ed wtth other local,state or tederal agencies Lo the extent neoess�ry <br /> t�i proc�se tMe permit or lioer�e. <br /> 4. If y�nur nequested permit or license requires Cour�al acfion � approve, some ir�#orr��tk�n may <br /> beaome pubi�. <br /> 5. Yc�u heve certain ri8hts under Minnesota State �tatube 13.d4 (se� fallow�ng page) to review <br /> private dats on yourseff. <br /> 6. Your full name Is required to prooess this applica#ion or permit. <br /> ��� I�l- <br /> First Middle Last <br /> 234� � a <br /> �d� <br /> � � nar� �t2-o ,c.�st�� �45I� <br /> City Sffite Zip � Phorte <br /> I understan y ri as e <br /> Si�nature <br /> R�C�IVED <br /> OC� �.i 2415 <br /> c�n oF oRorao <br /> Pedlat Lsst UFidatee�: At�rst 2a15 <br /> Page 13 <br /> � � � �� <br />