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� DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects bf.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 /> . l. <br /> 1. The information you furnish will be used to�determin�.your qualification for the permit�or <br /> � license requested. ; j � <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 /> , <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 /> 1�r l A�t� �.2�5�•� <br /> First Middle Last . <br /> �-/�/ ��� Si �-to� i <br /> Address <br /> ;F,T p (���. I'`�'ItiP. � �S'33� `�S2-y7�f�G�l�z� <br /> City State; ; Zip Phone <br /> . I understand my� ' hts as st ed above. . , � <br /> � Signature � <br /> • ; <br /> .�-,.�. ,.�-?;: <br /> � �-.•°—�:: .ez., <br /> �/ � y �� �� !, ;, ..,f. <br /> jL„y{;. �'"�.ii j � i <br /> Ca,.'T�!� 8>-- :��:' ;. � . <br /> P�'��%�.I ���4{�' '�• �� '���i <br /> /•'i <br /> �s :{� '�.f f A;.f r...—.-.�., '-•`—' �'`'O'�+�.`..i v. <br /> ` <br /> f J� ��?�1� , <br />