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DA7A PR9VACY 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 ifs departments may <br /> require you to furnish certain �rivate or confidential infiormation. <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 ta supply data, but refusal may require that the Cify 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 pro s this application or pe mit. <br /> F�— <br /> f?G �� ` <br /> i '� ' <br /> First t Jiiddle Last <br /> � � � <br /> Add ess /'� � / �^/ '� .G / � <br /> C� ��Y V�J i' !'�f �J ✓ /l /2 a J�J `/ .��/ <br /> . City State Zip P oh n� <br /> � <br /> I understand� y rig� �s s stated �ov . <br /> / � . <br /> ? n �. / <br /> Signatur �" (, �l ;� <br /> i� �/ <br /> �, <br /> :�.r^^�*. �;--�;��,r � <br /> fc� d:��' 'a � <br /> . �y � �'`•YeT�:t...� �LT��w,t ,� ., !.. r • <br /> ! 'f� `i;•`� �' � t'.� 1`t '� f <br /> .. �.,,1..$��r �.� f y . : . <br /> �� i' tr.:r. . {:j •.,::?at..�:. :��'"5� . <br /> j' t:.' <br /> l3i" S'"!?�L:'i1 y. ,'.1"� It('� f'• f J '' " ^ �j � <br /> f.• jt.�t,�. � "-L:'^riF''!y <br /> � v{�'J (' ��^-'e'.'.� �'�;;`.u:iv �l� '?,�;o:.'✓ <br /> 3 F� � <br /> tii:C;�%Z' <br />