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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 refusa( 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 /> S�Z� N i�VS�� M �O S <br /> First Middle Last <br /> 2l lvo w��s�� -tfi c�s � <br /> AaVVi4 T-�,�t-�4 Iv�� 5�5�1 l �i SZ— �{�Co—�q�5� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> �� <br /> Signature <br /> �; r r <br /> C_1/� (' J �_... � _ � „ <br /> ��/ � <br /> �� �.. .- v.._ -�-• - • <br /> �� [ i <br />