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DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "F2ights of subJects of data", we would like to inform you <br /> tl�at 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 infonnation, <br /> You are notified ihat: <br /> 1. Tiie infonnation you furnish will be used to determine your qualification for tlie permit or <br /> license reyuested. <br /> 2, You may refuse to supply data, but refusal may require that the City cleny the permit or <br /> license. <br /> 3. The information may be shared with othei� 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 /> Michael G. Hart � <br /> Kristin J. Hart <br /> First Middle Last <br /> 1005 Linden lane <br /> Acldress <br /> Orono MN 55364 763-502-1400 <br /> City State Zip Phone <br /> I un�ersland my riyhis stated above. <br /> ( <br /> Signature <br /> f`� rr.J .� a— 1"'� /� �''_, /�,-,�R� <br />� � f.j�4/ a /.� ^�� K � � F, � t � 1 � <br /> ,,� 4% �, � i. , ; 4 . <br /> � f� � �=- ��. <br /> �' r.- � ' `� ,� :: <br /> ���f ;.? � � • ... �% t � ! .� :i <br /> .�, ��' c�+��:i;:F� af _....,;..' ��..�.�.s�.> :t <br /> �4 r.,,. <br />