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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 inforrnation. <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 /> �"�w rw�s �. �2�.�(L� � � � <br /> First � Middle Last � <br /> �-2�( �a�T l�Q,� S�v��_�r � <br /> A dress <br /> (�i.(C� 1iJ 3S-� �s z-�(� � -z z�3 <br /> City . . State Zip Phone <br /> I under nd y hts as stated above. <br /> � Z _ �, ^ o � <br /> Signa ure <br /> ;� ;� •:,�.� <�:� F�� ;�,, , •;F.'="-_, <br /> �e r '��"�q E'wt•.; ,.�:*�.,�� ,�::'' ,�`;'; <br /> r �'��y; , �; ` �'i :�� :: <br /> ��"� � + ° >•`' r' . <br /> - �-Mp.. �,! .'_ ` �,. � (�y.� <br /> {�'I fT� f' S�� 5-: �.�;-� t��1 �([',�(y'L/�/ <br /> F" �J �'y��� T.:'.s.�-e:.GiO 1'e•� �.e'r7<✓" ' <br /> ��. <br />