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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 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 /> �1-{°/�� (� tt��v'����af� <br /> First Middle Last <br /> `��a�!� °�1�!'��1/ � <br /> Address ' <br /> �.�,i.�`��..�`i°.� ��J ��� 9 ���.° �1�����1� <br /> City � State Zip Phone <br /> I understa y i � ts s stated above. <br /> Signature <br /> . <br /> r:N-"`yir� q� <br /> � ' � raV� �: � �� <br /> !"�J � �!'�� .,'� �� �:.� (.i.l �f; N {f <br /> � i � /��� � �`� { � � �}y <br /> ,'��. l <br /> y r <br /> � / <br /> ��.� !�' � l .� <br /> f 1r ..' C l.ti• k� ,�..�a `;� <br /> �e' .y�,,:.ex , - �l � <br /> ���� ,... . .! �. ~i':.�::.c� <br /> � � �'{: u .._�+' <br />