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-�. <br /> � O ' V <br /> 0 0 <br /> � CITY of ORONO <br /> �, ,, '�_ ,�+ at�;�t ot�� <br /> :; : ,� rost offiCe saX 66 <br /> �� '� Crr�stal Bay,�iinnesota 55323-0066 <br /> �'��, : . -. •��J <br /> �kEsK�4 <br /> DATA PRIVACY ADVISORY <br /> In accordance ���ith �1.5. 13.04, Subd. 2, "Riahts of subjects of data , we would like to <br /> ,. <br /> inform ��ou that your request ror a permit or license from �he 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 ��ou furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> �. You mav refuse to suppl�� data, but refusal may require that the City deny the <br /> pei,nit or license. <br /> .;. The information may be shared with other local, state or federal agencies to the <br /> extent necessar}� to p:ocess �he perm�t or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> ini�ormation may becom� puolic. <br /> 5. You have cer�ain ri;hts under M.S. 13.04 (see followin� paQe) to review private <br /> data on vourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRLNT <br /> I� 'I;?�` ���-� <br /> First Nfidd:e Last <br /> ��� �� �� � <br /> Address <br /> l�� Z��� � SS ��� �l �� -1S �" � Z <br /> Cirv State Zip Phone <br /> I understand my riahts as stated above. <br /> , <br /> � <br /> � ' �y �� , �,,� � � �-� _ �-��-r� <br /> Si_nature <br /> � TEI.EPHO�V�-d73-73�7 • F�1Y--173-0510 <br /> 10 <br />