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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 <br /> to inform you that your request for a permit ar license from the City of Orono or any of its <br /> departments may 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 <br /> the permit or license requested. � <br /> 2. You may refuse to supply data, but refusal may require that the City deny <br /> the permit or license. <br /> 3. The information may be shared with other local, state orfederal agencies#o <br /> the e�ent necessary to process the permit ar license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> informatian may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review <br /> private data on yourself. <br /> 6. Your full name is required to process this application ar permit. <br /> �s P���-r S, Si'�r�l'` � g�� ���-�s�-� <br /> First Middle Last <br /> Z 3 2� � �r/.� <br /> Address <br /> �� l�c � �-��f /j'l,�( ��v�v � (�/2��2�-Dzzz <br /> City State Zip Phone <br /> I un rs i h � ed above. . <br /> Sign ure <br /> 8 <br /> �� //��''�''��. �.:;:. r� <br /> �{ (F(f� 2jµ J. f+:�.��_ r.. 'l,�ti Z� <br /> r�'' ��.�• ' '� �,Y S ' �5�'A' � {�Y� <br /> fix .�., ��� �� �r;{�' t� 1 .'1 rC.;f <br /> F "`�� � �y <br /> J,y}{N. ::.',y. - r . <br /> ��J�� ) r . 1 , - t. <br /> � �[�i `,'�,m . s,i .�'�� .:1 �� � I l'...t°:• ..�t: <br /> �b" L:t:'.;`}.'� :'.iJl L{ „Sir�.1,L'L3�V <br /> L <br />