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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 /> thaf 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 wili 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 /> _ _ <br /> 3,: The information may be shared with other local, state or federal agencies to the extent <br /> � necessary toprocess 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 /> yflurself. _ <br /> 6, Your full name is required to process this application or permit. <br /> � ,A a.� i,��r�:�,o �,4.,r�� ;.l <br /> First Middle Last - <br /> `1�H� `( �✓L1Gi'��,.1,, L.J t�l- <br /> Address <br /> P,.-r�a��,-�- . ►�.-�,J j 5�y Z �-�3-�s-�-9 3 yl <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> � .�—...___---- . <br /> Signature � <br /> �r �, _ - "� <br /> � , i <br /> � /� ��. � � � <br /> ��� �s '` <br /> � ... � ..A..��l� l'_-r--i1-� .�_..u._.!'` <br />