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� <br /> ° .� <br /> 0 0 <br /> CITY of ORONO <br /> ,.� l,'�• ,� .tunkspal otF�es <br /> r$,�" . .a c� Post O�ce Box 66 <br /> ,� •� '`:Y .�. �j~' Cr}stal Ba},�finnesota 55323-0066 <br /> �9kESH�4� <br /> DATA PRIVACY ADVISORY <br /> In accordance «�ith '�1.5. 13.04, Subd. ?. "Riahts of subjects or data", we would like to <br /> inform you that your request ior a p�rmit or license from the Ciry of Orono or any of its <br /> departments may require ��ou to furnish certain pri`�ate or confidential information. <br /> You are notified that: <br /> l. The information ��ou furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> 2. You may refuse to supply data, but refusal ma�� require that the City deny the <br /> pennit or license. <br /> 3. The information may be shared ��ith other local, state or federal a�encies to the <br /> extent necessary to process �rce pe:Iilit 02' I1Cer�se. <br /> 4. If ��our requested permit or license requires Council action to approve, some <br /> information may becam� puolic. <br /> �. You ha��e cerain ri�hts under M.S. 13.04 lsee fo�lo«�inR paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL'�TT <br /> a 7 � ���'Z�"� � '�'' �.. �-�1►7�c.� <br /> First �Siddle Last <br /> �� 3cv t3 v ; �I �.� � <br /> Address <br /> lil)�t uZ�.�� I"�� 5 i��'� (t 'z� �7�-�1/`1-� <br /> Citv State Z:p Phone <br /> I understand my riahts as stated above. <br /> SiQ a r <br /> TEI.EPHO^IE-473-7357� F�J{-�373-�I O <br /> 10 <br />