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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 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 loca(, 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 /> �.t a-rx�t� l�.J �� <m,, . . <br /> Fi�t� S , 1Mid Last <br /> C �a-� �'�'� 1 00�. <br /> Address <br /> � n c�o I`�� s S 3 t � r 5'Z- y 7 3•/oc.���� <br /> City State Zip Phone <br /> I understand m rights as state abov . <br /> �--�J <br /> Signature ��Q�� � „A-,_ � � <br /> ..Jo�...:�L. ��'� � k-���� -d- U�m.Q.� . <br /> j �'v�z .3 <br /> I ,h/ ��s�'••�l:f J4� i., 4�Y uZi�:` ;f�.�7.. �, <br /> ���,;'�•y " �'� C`' x�i�! F�� i�� 4�;; � <br /> � tT��f' <t� ' c 7 C . <br /> F_n_y... ..',:: `n r� i}�Y -. �'r <br /> �l .�� P 7 s -I � ;:J � �i f�tiy l,l�f <br /> , . �-� Y:!� �.... . i' . 4'�'sei;::%� �,•,lr,�+,'aa,'�t�ri � <br />