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, ' � • , <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 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 /> � <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 nn,�,s E . l2�.��C�e � . <br /> First � Middle Last � <br /> ;.�I-2�( (;a�T �Q,� S�v� _�r . <br /> A dress <br /> (�� 11J 3S-� a S Z.-�l� � "Z Z.�� <br /> City . . . State Zip Phone <br /> � <br /> I under nd y hts as stated above. <br /> .- Z - Z. - o � <br /> Signa ure ' <br /> � <br /> , <br /> � <br /> � <br /> � <br /> � <br /> } � ;; ,.;,���;, _;,�:; �� :�, ;, -����:_� <br /> �! k <br /> .tl'f /Y: il' •:1� GY ; :i.4.,:o�,-j �'.;. <br /> ��,..15, �`. ��' �t.�:s �r `1 <br /> . i9F :f..4 'ii' : _.t 'y ;� s. <br /> ,r r� � � ,.t:� �::, � . <br /> '�{ ,:�.�, , : ,�: .. -� <br /> ' j,/ � 1 5' + �. ��' ln f• . <br /> T �J ":) '''.'1. <br /> ' £�� t,�N�.<%� �{� a:;:%3 �� ��t <br />