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DATA PRIVACY ADVISORY <br /> !n 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 local, state or federal agencies to the extent <br /> necessary to process the per.mit 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 /> In/'�`I!tc� G— 7"r1�1� <br /> First Middle Last <br /> ZIB N 5 k�.d..w�d �.f <br /> Address <br /> �r,w 1..,,1�.. ��/ SSD�r� 6�Z-8 L3-ry 32 <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> n i1 — <br /> - L/ <br /> Signature � <br /> �/ ..�.c,r. • �'� , • f" •;�� '�F <br /> � �r !;� - r;.��:, � :'. ��*. <br /> c.�•n:x•_:ii,�r <<i . ;� .�,., � �i ':3 •Y <br /> ?. • �,. •..; E •..,.r; � .:�= i= �� <br /> e�r��r::#�,,� - ..:., :, .' .i, . :,, ,:1 <br /> �� ,fl r.; ,•`� ..- _ t.� ...i lr....1�:w:-% +� <br /> � � ay. c.. �:� .;s::%. <br /> =E;::�: <br />