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DATA PRIVACY ADVISORY <br /> In accordance with M.S . 15. 165, "Rights of subj�cts of data" , <br /> we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may <br /> require you to furnish certain private or confidential inform- <br /> ation. <br /> You are notified that : � <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested . <br /> 2 . You may refuse to supply data, but refusal may require <br /> that the City deny the permit or license. <br /> 3 . The information may be shared with other local , state <br /> or� federal agencies to the extent necessary to process <br /> the permit or license. <br /> 4 . If your requested permit or license req�ires Council <br /> action to approve, some information may becom� public. <br /> 5 . You have certian rights under M.S . 15 . 165 to review <br /> private data on yourself. <br /> 6 . Your fulJ. name, and date of birth are required to process <br /> this application or permit. <br /> _ � -`� � � � ;ti_� ,, �. �c;� i:_ �- � :�, <br /> i C. �ll i �'�►�-, , f�_ , �� <br /> First Middle Last <br /> �I �'`� i `�_ I� Y�1��i�" ' i� ; <br /> Address <br /> � � � - -�� ��-- � <br /> J�-;..•,� ,.-� � ,�.,_ i � i <br /> `J <br /> 9 <br /> I <br /> ��`J ' i - ��' ��� c:�l <br /> Phone <br /> I un erstand my rights as stated above. <br /> �--/ ,� -� . � --- � <br /> X . "�✓�i,.Z.'` � � -�i-�i�. <br /> Signature <br />