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DATA PRIVACY ADVISORY <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 will 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 yourself. <br /> 6. Your full name is required to process this application or permit. <br /> ,t�?�� !-J i�-��— �• l�t�P�,c4 �'i L L !�- <br /> First Middle Last <br /> �� � ��i�t�/1 O� ✓�r�J�''! ��t�i- J� <br /> Address <br /> cr`.��.�.y�� /'����,�1�1� �J:�S�� ���C_ /�'�,�.�..�1�.1�� <br /> City State Zip Phone <br /> I understand my rights as stated a ove. <br /> ��,���__-.-J�..:�-^ 1`_���/\JLL� <br /> __.._..,_ .. � <br /> Signatur - <br /> 7 <br /> � ��J � <br /> ��;;.-��-, <br /> �� r <br />