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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 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 fulf name is required to process this application or permit. <br /> ����►7 i-� � ��ti:� '�uc S��'�'�d.1-� <br /> First Middle Last <br /> �0 Z d Lo�t,�G� p R�u'�..- <br /> Address <br /> �Tm.����.�,rt'rz.1b`��l �►� �.�36� �12- ���1-Od�� <br /> City State Zip Phone <br /> I understand right as st ed above. <br /> .,.�-, <br /> Signature <br /> r ,� r; ; ;J <br /> f' f >''` �=, !i <br /> _ I �K:'�� y',' s, ' <br /> �,_., .', �',._� <br /> /��� /�7.. �`� :::Y+—I.._.r'i.J C ,. ' ... <br /> / <br />