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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 /> 1 �r��.a `.t:�-�v..r � ��"a���z.-1�r..�+�°� <br /> First Middle Last <br /> �"1�� � �� ���.. I�t:i� <br /> Address <br /> �,�a..��.�. �.,..i S���I �� �C�`l ''-�3��`��'�';:� <br /> City State Zip Phone <br /> �.urad r-star�d-myr'r'�ht s stated�'Pvove. <br /> �, - <br /> Signature - - <br /> ��r ,�,"'�'�,. 'x`�� �� <br /> � 1n ` <br /> ��:1.rJ�l�:�.ir�J �� 'S`�I � � <br /> f:� r.,;��; ':.� <br /> 5�-�:j.s��a:� r'4� �! <br /> �/ �" t�i r� �,;;,-� <br /> �.>;u�a,• <br />