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DATA PRIVACY ADVfSORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br /> to inform you that your request for a permit or license from the City 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 wili be used to determine your qualification for <br /> the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny <br /> the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to <br /> the extent necessary to process the permit or license. � <br /> 4. If your requested permit or license requires Council action to approve, <br /> some information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review <br /> private data on yburself. <br /> 6. Your full name is required to process this application or permit. <br /> �.._ t,.,i->•1-.-�'.��.�" /y�� ��) ��i�..�.l� �V��`� (�-_•�'�, <br /> First Nliddle Last <br /> --.�� ,.; ., �_ �---- ;' 1 <br /> :i.� r�',I rJ��r�` :•I�=JE��� ` ..�'€/�:.... <br /> -- � _� '� . <br /> Address <br /> '�����-�� �/,k l� �����' �-.,�'�.'",i'�'�- ••i✓r�-.,� �"(%'� --.:� <br /> � d� ..J ! l C.�.._... <br /> City State � ~ Zip� Phone <br /> I understand my rights as stated:akrove. <br /> l , , <br /> _ , :-l� , <br /> , ,��_. , <br /> . ��: ,f-�--_._.___ � .��'` - y.. ._ n. . . <br /> Signature � ` <br /> �� <br /> t � <br /> ... ;- <br /> :I �,; <br />