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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 /> .� �� <br /> � 'rc��► tic:��.4A�f' c�.. ���`��'�-iMc:�.�^. <br /> First Middle Last <br /> �1�� � S`�� ik�-e.. lv�.;� <br /> Address <br /> �=>�-`�.^ ��.._i 5��i�I Z-�- ��`� 'tF:?��%�-`f�-�'� <br /> City State Zip Phone <br /> �<�pd r�sta�cf-my�r'r�ht s stated''�ove. � <br /> i <br /> �''' .:-_,_. <br /> --_. <br /> Signature � `�- � <br /> ��� � �^z��� ,�a ;;,f;�'�'s, <br /> � t• <br /> +' ��`' �'�c C� �,�wl <br /> E:Y1:�J'F,.y.,Fr) �ut� .G' �� ""`wP <br /> /� sr:1��^.6Y9 k�'l�� �..'� �.�. <br /> a.! LJ �y.,,�;�pl:;'��• kf'�� � <br />