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DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjecfs 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 departments 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 defermine 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 /> you rse If. <br /> 6. Your full name is required to process this application or permit. <br /> ��'i���� P C�.A C���� <br /> First Middle Last <br /> ��r� �-n R� ��s- �;4 L-Q.-, <br /> Address <br /> �rn�� ti .�-���.�� � � _ S'� 3 6� �� 2 �6 � �o�S� <br /> City State Zip Phone <br /> I understa d i hts stated above. <br /> Signature <br /> !? /? �— - �:, - - <br /> , _ <br /> . ,- ; <br /> i` f�� ti.�, ,�;;'.,� ��.� .... � '�.v�.. 4..�r � <br />