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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 to inform you <br /> that your request for a permit or license from the City of Orono or any of its departrnents may <br /> 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 local, 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 M.S. 13.04 (see following page) to review private data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �a-�'�-t - �-I I� �,� ����� <br /> First Middfe Last <br /> 3�(�C� �Yv � �cE� <br /> Addr , s <br /> , _ � 53 I � •� -J° �� <br /> City State Zip Phone <br /> I understa d my rights as stated�above. <br /> / .___.. <br /> �, _ ----- -- <br /> Signatu e � <br /> � � ���x� *i <br /> ,�� +, ;� �-�— , , <br /> �' C�'7 �L: Y�'g f',i a �:;p ���. <br /> ,.+r r.:,ti;,'.`,fl ",� �._:�. � � t.� <br /> � �..:! . t y r . <br /> �'!) � �': a�t';� <br /> r <br /> :,�:: 7�:._ ��it i.;;� <br /> t�4* �„�..�. . .., `r� ��f <br /> .. vutM �1,��1.iv <br />