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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br /> warning", we would like to inform you that your request for a permit or license from the City of Orono or <br /> any of its departments may require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or <br /> license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> license. <br /> 3. The information may be shared with other Iocal, state or federal agencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information <br /> may become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04 (see following page) to <br /> review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> C � �� � <br /> �l �G� ar��- �D �'.� <br /> First Middle Last <br /> �v� � <br /> Address <br /> ��0 <br /> ,�il� s.��Q ( 7�-5�6�6�I <br /> City State Zip Phone <br /> i understand m '�ght as stated abov�. <br /> W' ' � -------- - <br /> � <br /> Signature , <br /> Packet Last Updated: 04/19/2013 <br /> Page 20 of 23 <br />