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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 full name is required to process this application or permit. <br /> V� l � � n `� V� <br /> irst l Midd�le_ Last <br /> � <br /> A dres . ��S �' /� ����� 1��.�-�Sc� 9.� CJ <br /> City State Zip Phone <br /> I un rstand my rights a tated above. <br /> , <br /> Signature �. <br /> � � �, ,��� � <br /> ( ,; <br /> , �=� � <br /> ._ ; _ . <br /> , <br /> _.. <br /> , j �- <br /> ._ <br /> � �.�... .�:. .__..� ._.__ ` �' .� <br /> ., <br />