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/ <br /> / \� <br /> '� �� <br /> ;, o 0 <br /> -;;;;�;;;.�.-,_ -- � C IT�' of OROI\TO <br /> � � .�� _ . .� � .i��o� <br /> \;\'� !. �, ."6�_f . �,' , P�o�soX� <br /> ,\\,�, ,r.�y,�;:�:�,;����p"�' c���sa�,`�ta s�z�oo� <br /> \ �9kESH�g- <br /> DATA PRIVACY ADVI.SORY <br /> In accordance with M.S. 13.04, Subd. 2, "RiQhts of subjects oi data", we would like to <br /> inform vou that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine ��our qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the Ciry deny the <br /> pe�nit or license. <br /> 3. The information may be shared with other local, state or federal a�encies to the <br /> ext�nt necessary� to process th� permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become punlic. <br /> 5. You have cerain ri�hts under N1.S. 13.04 (see fo!lowina paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�'T <br /> ��-rn��S �� /Y) � C vti� <br /> First ��1idd;e Last <br /> /.y � 3 �3 � 1zr� �G� ��� <br /> Address <br /> ��C��c� ��/v`r� `J'r�`7� �lo?- '�73'3�2�.� <br /> Citv State Zip Phone <br /> I understand my riahts as stated abo��e. <br /> / <br /> �,;.. L' ��l'--[�T✓I't..rZ <br /> Sianarure <br /> � �t.�Pxo��-a�-r3s�• Fa.X-.��osio <br /> 10 <br />