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� �� <br /> /'� O ` V <br /> i <br /> ,; � ::. "� \'`� '�Y of ORONO <br /> ,; _ _ CI <br /> � ��; `'P=� as��o� <br /> �1�+� '�`�����'�_:.r, �'' , P�o�soX�s <br /> ��, ti , c�s��oo� <br /> \\�. ��� S. jl:; -� ,�, c���B�y,`� <br /> � �''��/' ';:r ��� �J <br /> ' ","1; _��' � <br /> , . . _.. <br /> \L9k.��g'/ ; <br /> DATA PRTVACZ' ��ORY <br /> In accordan�e with 1�1.5. 13.0�> Subd• `licensaetfroms the Ciryr f Orono or�an loi ics <br /> inform ��ou that your request for a permit or <br /> de�arunen�s may require ��ou to furzish certain private or confidential inforr.�ation. <br /> �"ou are notiiied that: <br /> 1 Z-h� intormation you furnish wi11 be used to determine your qualification ior t e <br /> pe:mit or lice:Lse requested. <br /> �. You may refuse to suoply data, but refusal may require that the City deny the <br /> pe.,-nit or licease. <br /> 3. The inrormation may be shared with oth= license.state or federal aaencies to the <br /> extznt necessary to process the permit o <br /> �. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> �. You have certain ri�hts under M.S. 13.04 (see followin� paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLE�SE PRL'�'T <br /> � v� S /`'1 ��y�i�a�'G �1=�'v � � <br /> First <br /> Nfiddl� Last <br /> � � <br /> �3 � � s�� � " <br /> Address <br /> � �- , � ` �� - �/ � <br /> �,�, �� C,/� ��i <br /> /�7/�' � 7 3� <br /> S tate <br /> Zip Phone <br /> Ciry <br /> I understand my riahts as stated above. <br /> /.�� � // <br /> � - �` <br /> , <br /> Sia ature � <br /> TELEPHONE-�173-'3�7• E�.Y-373-0510 <br /> 10 <br />