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_ � <br /> ,-� �? <br /> � ' Y <br /> O -: � � <br /> - C�T�" o� OROI�T <br /> �a ,:, ;f;:�`.- ,� `���o� <br /> �� l,� .P '�_ � Post O�ce Box 66 <br /> . .� ,�- 'l:� � -- .� /'.~ CI'VSL'1��2Y��IIIII1f50L2�7����G <br /> • j \J <br /> ��kESH04� <br /> _�_,,- <br /> DAT� PRIVaCY ADVLSORY <br /> In accordance �;-ith �1.5. 1�.04. Subd. ?, "Rivhts of subjects o� daca", we would like to <br /> inTorm you that your req_uest ior a p�:r.1i� or license irom the Ciry oi Orono or any oi its <br /> departments may require �-ou �o iurnisn c:.rcain pri��a�e or conTidential intorm.ation. <br /> You are notified that: <br /> 1. The info�nation ��eu f�srnish will be used to determine }�our qualirication for the <br /> permit or license requested. <br /> �. You may refuse to suopl}� data. but retusal may require that the City dery the <br /> pernit or �icense. <br /> 3. The L*�rormation may be shared �vith other local, state or fed�ral aQencies to t?�.e <br /> e�cter�t necessary to p.'�cess �:�� Pe:rzit or license. <br /> :�. If ��our requested pe:�mit or Iicense requires Council actiorA to approve, some <br /> intormation mav becom� puoiic. <br /> �. You ha��� ce::ain ri�rts und�: �1.S. 13.0^ (see fo�lo�j�in, paa-) to revie�v private <br /> data on yourself. <br /> 6, Your full name is reauired to process this application or pe:mit. <br /> PLEA�E PRLV'T <br /> ��� � �� j'�L1� �i 1-- yii �C�- <br /> First �Iiad:e Last <br /> f� ._, <br /> � ,� . � ,_ ,t , ��� <br /> L <br /> .�ddress <br /> --, �Y�s � ,���a �3 �,� l �/ '7 / -'1 � _j�-, <br /> ( � L ��� Sta�e Zip Pr�one <br /> C lry <br /> I understand my riahts as staced above. <br /> . � 4 - '����'Z.�j�''J/ <br /> ,s � l i <br /> Sianarure � <br /> � TEI.EPiIO?YE—473-73�• E4X-173-0510 <br />