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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 refusaf 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 /> . ,,✓J <br /> ��P-�J ����rn�'� ��7����-c�- , <br /> First/-•� � 1� Middle Last <br /> V C7 G l'�����i'�./J�. �i,� . <br /> Address <br /> � .�,�- � � �S-� 31 �Iz���� -�-��� <br /> City State Zip Phone <br /> I understand my rigj� s s tated above. <br /> r'� . .�...._._.........._...... . <br /> � <br /> Signature <br /> i�`:� <br /> � ..3 <br /> ..,.� - . . <br /> ;�-. �_ <br /> _ - .:�° � ° ... � . <br /> _�:�J�-t: �.._.. . _ <br />