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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 /> �� �cl� ���'v-� �SS <br /> . First Midd e � Last <br /> 1r7(�D <br /> Address <br /> �ro�o M� �s�� 1 qs-z=a7l��.�o <br /> City State Zip Phone <br /> I understand my rights as stated above. � <br /> �(���ilJ-�—�.C/�!C.�-�-� <br /> Signature <br /> �s �^' °�'` , ... ��"�— �;,;� <br /> , . . . ,�.., <br /> � >:��,_;;a �;:; . �� <br /> .��..`�/� �,. � � � <br /> � .s, �...., , ;, : ,... � <br /> �/ �� ��-.. . ..i�`�... ' ---•�,. ,,..... .... <br /> �'wa..._.. r:,r :r, �:,..,..,� <br />