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• . DATA PRlVACY 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 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 fu(I name is required to process this application or permit. � <br /> ; �C��7•.C�if>Yl�. 1 V ICR.I`i t° cl c��irl ��°1 � � <br /> First Middle Last � � <br /> � ��� �nl� t„�ir�� . <br /> Address <br /> ��c9�VYa I�`�� .55�� �/76"v;7�0 <br /> City State Zip Phone <br /> � <br /> I understand my rights as stated above. ' <br /> �� � � <br /> Signature : <br /> � <br /> t <br /> r� •� f��Z''•,ti z <br /> ':���\��� Cia�y !� .:�� �V+�i <br /> ` c�� i�•,f i .a;•r° i <br /> C.�' �.�zr: ' ' '�.,, � . <br /> r �;�: � 4.;:-:.:;... ,:l �;� <br /> . �� ::r .._ . . ... , ..�:�%:.:�' : <br /> , �`'4.J , . ::1 <br /> ..�.. . ; <br /> ; � . <br /> � ;. . <br />