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� i '� - <br /> . 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 noti�ed that: .� � � . � _. : <br /> 1. .The information you�furnish will be used to�determine your qualification for the permirt��o� . � <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 fo process this application or permit. � � <br /> ���m � �� l— {�i'�.n r c c, � . . . :.. . <br /> _ <br /> First .. � - Middle . Last � �. . � : . <br /> �5SS �P��r t�l� .57�"" . . . . � . . <br /> Add ess � . � � � •� <br /> �,�(�,c�l�..�-- �'Vi-'Yl � -S�S� 3 9 r ��i�a�-/l�-�c���� � <br /> City � . � State � Zip � . � Phone . , <br /> I understand my rights as stated above. � . � � � � " � � . � . . � <br /> C.., ��'" -�( ' . . <br /> Sign re � � � • � � � � <br /> -�,- f:7 0 � T :• -,,. <br /> i „r- '?y<:1 c�. , � �y ,,,::; �:;x.. :r <br /> � ..-.y a;�� , j; � � �'... r,� A <br /> I`" "" .``.�l '+ F . <br /> .,t���� �<,:., t;f . ... , <br /> . Gtl Lt ., " �<;. :.r.-,�'%• <br /> '':t. .,: �.���•• � <br /> f �'>.� �:• ` � '+ <br /> �';:�i^:;u%��� c�i�,:«,_ �� ;ai;,:,,.;�,.�,,:;;' �d <br /> � �� �� y � <br />