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. <br /> 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 refusa( 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 /> , ( <br /> ���� t �m�,�s 1,����-��.�-- . <br /> First/, � Middle Last <br /> v G(�'�����1�. �.� <br /> Address � 1 � .�'s,� �� �j�Z,��v•-2�� <br /> City State Zip Phone <br /> I understand my rig� s s tated above. <br /> �� ,..._,..._�_.__........_...... . <br /> Signature <br /> r:-.; <br /> , . <br /> '�� <br /> � . . � ..., . <br /> ;� � � � �-- <br /> - .,�':•� ° ... . � <br /> -ill�1' �... � <br />