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. L� � �2- <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 /> �i''t�C'�'. - �"�G�`,�"�'-c�..J ���'4��,�;���,r�-��' <br /> First Midale Last <br /> �� �� `'f���������6"��C,. ��".,, ��. <br /> Address <br /> �r�.�z��d�, ���1 �S3g/ ��s�z�����'-���.5�� <br /> City State Zip � Phone <br /> I understand m,X rights as stated above;,, ? <br /> ff .��� �% <br /> /�� --/li�A,�'iP. `°" �' ' �' 4 v.A..-,_.i- -Za�i- ,��.�.�'✓s----°"""�—__.. <br /> Signature <br /> -.V -� <br /> -�,� ' G,x, f .. � f �_� <br /> � ; §".+ t : i '1 � i �; <br /> e�.� � �;'7 <br /> J <br /> - l f�,. YJ.'. 5� ���I <br /> . �r ,��� {.i`� ,♦,��'� � '� �; � ,�a1 <br /> L/ '��,���s l,r:,��iwi :::u�+>' ���.:� ,f;J <br /> ,� <br />