Laserfiche WebLink
t <br /> . <br /> --_�-_ <br /> r O �, <br /> � <br /> Q � <br /> - c�TY o� oRONo <br /> ����� � �, �r�;�� � � �t���o� <br /> � ,�'r . ,� _ ,� Posc ot�ice sox 66 <br /> .�. � '`". .��,j�...�� ,''��r � CC)'S�B3V,�'illlllfSOta J�3Z� <br /> �9kESH�4� <br /> -_- <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "RiQhts of subjects oi data", we would like to <br /> inform you that your request for a permit or license from the Ciry 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 you 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 may require that the Ciry deny the <br /> pennit or t�cense. <br /> 3. The information may be shared with other local, state or federal agencies to tr:e <br /> exter�t necessary to process th,: permit or license. <br /> 4. If vour requested permit or license requires Council action to approve, some <br /> information may become pubiic. <br /> �. You have cer�ain ri;hts under M.S. 13.0? (see follo«�in� paQe) to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> PLEASE PRL\T �" �l � Y "� ��� ��i.(, i l..IU�=�� �� /��� <br /> �� "j f:i�, N N I��F��' 1 i� ��'J F�(4�S<:'11,I <br /> First Midd:e Last <br /> 1 S� i 3 - � � L�l�� ���tit <br /> Address <br /> h�hKNs�� I LL� r���v �� s� � �} 3�- ��f'�3 <br /> Citv State Zip Phone <br /> I understand my riahts as stated above. <br /> � <br /> � � <br /> ���Z1����4�� �� 4 �� <br /> Sianature <br /> v TEI.EPHO!V�E-473-7357• F.aY-a73-O510 <br /> ?Q <br />