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, � � ����• U4i 1�7/LUUU U�7.J�7 itUl/ � .UUJ <br /> . r+rn-ty-c�iun�wtu f u�, nc f�. ��u�iuui <br /> . � <br /> DATA PRIVAC_ AtaV1SORY <br /> Jn accordan�e with M.S. �i3,04,Subd,2, "R(ghts of subJects of data",we would like to inform you ' <br /> that yaur request for a permit or license from the CIry af Orono or any vf it�depariments may <br /> requira you to fumish ce�tain privat�or confider�tial informetion. . <br /> I <br /> Ypu are notifted that: . <br /> 1.• The lrtformation yau fumish wifl be used to determine your qualifioat(on far the permlt or <br /> li�anse requesked. • � , . <br /> � 2. Yvu may r�fu�e to suppiy data, but refusal may requlre tttat fh�Cfty deny the perm�t or . <br /> Ilcense. <br /> • 3. The informetton may be shared wtt�ot��r lacal,state 6r federal agencies to the extent <br /> • ' • necessery to proGess the permtt or l)cense. , <br /> ' �. If yvur requ�sted pemnit or licanse raquires Council adion to approva�same infarmaiton <br /> may bocome publlc. • <br /> 5. You have r.�rtaln rlgh�c under M.S. 13.04(see following page) to review private data on - <br /> youiselF. • <br /> . 6, Yvurfull name is requlrad ta procass thi�applicatien,er permi�. � <br /> �6 Y CU'7 h� �` ' '�'1 i°eC.f01'� � N��hV1��t l^�kt� ��'li Cv �r�'�'�e' �Ir-+.5 <br /> Firat Middle� Last ~ <br /> a Z�/!J iVOr il�h �tn DI!Wz-- • . . <br /> _�y�.a.� �'�'i'nl �5�9� L75�, y 3 T �.� i <br /> 7 3 �x t � <br /> � <br /> CIly S�tate Zip • Pf�one • <br /> I un tsnd my Nghts.as steted abvve. . <br /> I s�/r�/� � <br /> . ig atu ' <br /> t <br /> . , � � <br /> . � . . , <br /> � ' � � <br /> i ' <br /> ,; .. <br /> :� '� ' <br /> .. .�` t�����'7. /�F� �r� �. <br /> �-��.` � �t?.4 .� L i l �` U <br /> 6}�� 'i� ��� 4L•'�tL -'.{ 'f) �e <br /> • W�, l�, ;t :. <br /> � Y� '•r`'` }'� ����� �� lF��i <br /> �y <br /> '� f,� �. '�� ¢v'.==4i� <br /> 5 a� � �'s,.=„`�%: <br />