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TY OF ORONO � 6124730510 09/24/96 14:00 �1 :03/03 N0:522 <br /> Sec.13.04 ItIGI�TS OF SUHJECTS OF D�11".� <br /> Suhd. 1. Type of dats. '1'tte dphtt of indlvidud oi1�hom tha dar�i9 arored oc ro be scorcd s6a1!be as set foith fn this secdan. <br /> Subd.�. Inlonoatloe riqtdr�d to ba�lrtn indl�+idu�t. M ledividurl asked ro supply privta or confidentiel daa cancerning hitnaelf ahall <br /> be fnfonned of: (�)d�e purpose�nd inranded uae ot�he requescai d�p�wirhin rhe colteednQ bn�e agenoy,polldeal aubdivision,or snreWide rystem: <br /> (b)wfiether he may refl�Se oT i!IegWy►equired rn supply the roquesred�u;(c)any knoam conuque�u;e ariatng from hfs supplytn�or mllising ro supply <br /> privace or coaMen�i�l dara;and(d)�he idenrity of odu�person�or tnddes authorized by sum or fedecal law m reneive the da►a. T6�requireme�c shull <br /> not tpply when an individuet i�nsked�o eupply(nvesrig�dve daa, pursuan�co ceedon 13.82, subdivision S,to�law enforcement o(ficer. <br /> a cumm,i�sgnec (revenue mav alace the noqce rcwirad under is subdi�isiQ in �t e individuel ;ncome rax ar oroosm ma;re�ind <br /> «ucdont�q mud e�on�ioic form�. <br /> SuEd. 3. A�ce�e to data by ind(ridual. Upon rcques�to a rcsponsible�u�horiry,sn iadi�idual shall be informed whether he le�he s��bJeee <br /> ot�wrod daa on individuals,and whe�ar ic is elnssified��public, privam or conPldendal, Upon 6is fl�rtber rcquea[,an individual who 1�rhe subjact <br /> of soo�rd pri���e or public da�a on indivi�uals sFull be sho�+m rhe dara wl�houc any charae w him and:if hc deaires,ahall be infortmd of the conronc <br /> and m�aning of dis�t dam. After�n individual ha9 been shown rhe prl�eta d4ra and inlortncd of irs axsning.d►e daa eeed noc be diaelosed to him for <br /> •{:uwnrhs sheresfur unl::s:dispu�E or vecion pureuanc w �his scedon is pendin�or addi�onrl dara on�he individual has been oollecced or crea�J. <br /> '11+a rsepnnaible�uthpriry ch�ll provide copies of rhe privare or public dea upon rcquesc Dy�he ind(vidual cubjecc of d�e dan, 7?rc re�ponsible au�hariry <br /> m�y requite the requeedn�parson ro pry d+e aemel cosrs of mak(ng.certilyino.u�d compf8ag rhe eopi�s. <br /> The responsible au�hariry ehall comply immediatsly, if possible,wi�h aar rcquest made pursuant w�his subdivision,or withln fi�e days of <br /> �e date of the reyuose,excludina Samrdays.Sundays�nd legd holldays,iF immedla�e compliance is not possible. 1Nhe cartno�comply with rhe roques� <br /> wirhin tha[dme,ho ahali ea in�orm tha lndividual,and may ha�e an oddition�l flve days wldiin which m comply whh the roquest,axcludltig Sapudays. <br /> Suml�ya And leawl holid�ye. <br /> Subd.4, Roeedure wh�n dnte:s net oceurata or eompl�te. An indi�i�lusl m�y conms�the accuracy or complaeno�of public or privrce <br /> d�u concernln�himself. To exercise rhis dght,vn indiViduel shall no6fy�n wridnP ehe respunsibie�urhudry�escribina d►e newro of�he dlcagreemenc. <br /> The rexpen�lble authority sliell within 30 days either: (a)correcc the dam found eo be inaccun►te or incompte�e nnd etrempt to n�dfy�ut reeipients eE <br /> ieaeeue�te or inc:aruplete dpa, Includin�recipienu n�med by rhe indivldual;or(b)nodty�he individual thec he belleves the dem m be oorreei. Dam <br /> ip�l�pute ihsll be diacloaed only if the indlvidusl's sniement of disaoceemnnt is included wirh�he discloaed dara. " <br /> '�'he determinn�ion ol ihe rrsponsil�It sud�oriry may be appeated pursueni eo the pm�isionc ol�he adminis�nrive proceduro act rclaring w <br /> eonte9ted Cases. . <br /> ' �ATA PRYVACY ADVI$ORY <br /> ln accordance with M.S. 13.04, Subd.2, "Righ�s of su6Jects af da[a", we would like to inPorm you that your request <br /> for e parmi[ or llcense from the City of Orono or any of its depanments may requira you eo furnish certain private or <br /> confidential information. <br /> 'You are nottfied that: <br /> 1. The informetion you furnish witl be used to decermine your qualification for the permic or iicense requested. <br /> 2. You may refuse co supply daca, buc refusal may require thac the City deny the permit or license. <br /> 3. 7'he information may be shared with othcr loeal� stato or fedeYal agencies to the excent necessnry to process <br /> thc permic or licensa <br /> 4. . if yout requeeted permit or license requires Couaci! action to app�ove, some infprmatlon may becomc <br /> ' pubtic. <br /> 5. You have certain rights under M.S. 13,04 (avvlable upon request) to review private data on youcself. <br /> 6, Your full name is requir�d to process this application or permic. <br /> L � � I � <br /> � Firs�, � j - Mid . .� I LfiL <br /> ' 1 �"�1 <br /> � � � ��� � ���I��r �����1 � -- ��j <br /> Cl�y Sooe Zip Phon� <br /> � <br /> ' 1•uaderatan my dghts as staced above <br /> � �,`' ��. <br /> sia " ro <br /> Dww. . .._ I T!. /� /�I 1 1AT1f T. ' 1 In� n n . . .nw�• <br />