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I <br /> 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 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 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�lk �an�ii� �a�l'�-�+�. <br /> First , iddle Last <br /> 1375 �1��..L !`�lac� � <br /> AddrOd'OhrD 1"� tv SJ'r36"I �J'rZ'�7Z'�Jr� <br /> City State Zip Phone <br /> I understand my rights stat above. <br /> s-�io es <br /> Signature <br /> � ��'' �/, 4 T� r ,�' t �' �! <br /> �.�, �/,,; _ i : � <br /> i <br /> L���� � :i .;\i ... ��1... <br /> !v� '�. � �� y._�_;_:i _,:::�1 .: �:.` ,.,, <br />