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Ju1-18-2006 09:OOam From-CITY OF ORONO +9521494616 T-653 P.002/002 F-641 <br /> ' Sec13.04 RJCF�7S OF SUBJECTS OF AA7A <br /> Subd.l_ Type o[daca. The rlghts o(Individual o■whom�he dsta is ttorsd or es bc nored ahali bc aa act torth in t`ie aectioo. <br /> ' Subd.2. Informa�ion requircd to be glven tadividual. An individual owked m supply privau or mnTidontial data eoncrrnins Aimbclf Yhall bt <br /> informed of: (a)che purposo eoe in[ended use of the requeatc�l daa wf�hln tha cuurctiog atatc apency,politicsl subdivieion,or atntcwide aynem;(b) . <br /> wbetber de may rc[use or is tcgally required m sappy the nquesud d,tn;(c)rny laown consequence��Is(ng irom Afs supplying or re(using to supph• <br /> privrroor eonfidential d�ta;and(d)the iden[iry of o�he1'pareone or enti[iea autborized by state or fednra!law to receive the dau. Tdis roquircment shstl <br /> eo[apply when an individual is Osked�o supply investig$tlre da�A,punuant to scctio�13.82,aubdivitioa 5,[o o low enforeemtac officer. <br /> Tke eommissioner o(rt�enue mav nlace tAc nO�iC!rtnulred nnder thic subAivision in��e indiviUual incomc ta:Or orooerb taY rlfunQ <br /> instraMiOns inscead of nn thoze fortns. <br /> Subd.3. Acccss to data by individwal. Upon rrqucst ro a responsible authoriry,an individua7 shaU�e inloTmed whethor ha ia the subjca of <br /> smred avn on individuala,sed whetAer ie;s claasiRed as publ(c,prirau or conUaeniial. Upon Y�turther reques[,nn inaividual wl�o is the subjec�of <br /> crored prlvate or public dar,on individuals shall be cdowo idr da�a wirhout any cbarge to him and,if he desf�a,�hall bt informed n(tbe mntont sad <br /> moaaing of that dAta. After aa Individual hae bCea shown the prlvAte data aatl in[nrmed of ite meAniog,Lhe datu neM not bc dutiosed to him for clY <br /> mon�hs thereaiter unless a dispuec or uecion pursuan�to this aaceion is peading or additlonal dxa on the Indlvldual has been colleaed or created. The <br /> �¢sponsiblc authoriry shnll provlde Copits of the prirate or publ(t data upon rcqucst by thc inCividual subject uf tAe data. Thc rcaponsihle nutboriry mo�' <br /> require�he requesting nenon w p�y rhe ae�ual wm of maldng,certifyiog,and complling the eopies. <br /> Thc�csponsible authoriry�hall oomp�y immcdiatcty,if pobsible,wlth any Pequcst made pursosnt ta this suDdivision,or within�ivc days of thc <br /> dste of thc mqueSt,cx¢luding Sa�u�dllys,auadays s�d legall holiQays,I(Immediatc eomplinnCe is no[po6sible.Tf he mnnot comply with the rrqutbY withfo <br /> chrr rimG Ae shall so In(orm the indivioual,aad may a�ve an aQditlooal Gve aays wi�hin whkd w oomply witA iAe request,excluding 5sturdays,Sunds.�s <br /> and Itg�l holid�ys. <br /> Subd.4. Procedurewhcndowiseotsccursteoreompletr. Anindividu�lmaycontes�theaccuracyorcampleteneasofpubtico�pri.�ateda� <br /> concerning himselL To exe�ciie thls rlght,sn indiriduAl bhall Aoiify In writin�the rr6ponei6lt authoriry Gescribing the nnturr of tht disagrtemen[.TAe <br /> ►esponsibla aut6urity shnll wi�hiu 30 d8y7 el�hcr: (s)mrreCl tht dAt�foqnd to 6e inaccurate or inmmplete and aKempt to natify paxt rccipicnte 0f <br /> inaccurate or Incomplete dua,including recipien�named by the iadividunl;or(D)eotlfy�he Indlvldual iAa��e Delieves the daw w be correct. DA[8 IO <br /> dispute sha�l be disdosed only if Ihe ladividual's strtemtn[of disagreement is incladrd witA the disclusrd drta, <br /> The determination of rhe responslble authority may be appealed pursusnt[o the provlstons of the adminissradve procedure sct retatin;ta <br /> contestcd c9ses. <br /> DATA PRrvaCY AbVYSORY <br /> In accordance with M.S.]3.04,Subd.2,"Rights of subjects of data",we would like to inform you thut your request <br /> for a permit or license fYom the City of Orono or any o!tu departmenu may require you to furnish certaia private ur <br /> confideatial information. <br /> You are notf�ied that: <br /> I. The infarmac5on you furnish wilt be used to determine your qaxlification for the per�rit or liceose requested. <br /> 2. You may refuse to supply data,but ref�sal may require that the City deay the permit or licease. <br /> 3. The informatioa may be sbared with other local,etate or federai ngepcies to the extent aecessary to process <br /> the permit or license. <br /> 4. If your requested permit or license requires Councit action to spprove, some information may become <br /> public. <br /> 5, You have certafn rights under M.S.13.04(available upon request)to review private duta on yourself. <br /> 6. Your full name is required to process thfs application or permit� <br /> ��rc: �-c�z— Ve G-s71�� <br /> First MidAle (,ast <br /> �� �'2� C��c'� �i�.�'T� (Zo�'�-(� <br /> AQdreu <br /> _ � �z� �� �s��� C ���- aso -�� <br /> Ciq Snoc Zip Pbooc <br /> I understand my rights as state above <br /> Signaturc <br />