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DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we wouid fike 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 informatior�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 wi#h 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 requices Council action to approve, some information � <br /> may become public. � <br /> : 5. You have certain rights-under M,S. 13.0.4 (see following page) to�review private data on <br /> . . yourself.• • ' . ' ' • • � <br /> 6. Your full name is required to process this application�or permit. � <br /> cn�vcEpT�ANosca�w� <br /> First 31,�3:�'AIEST�t;� Middle Last . � <br /> tiAOIiND;MN. 5536�i . � <br /> Address . � � <br /> City State Zip � Phone <br /> I understand m ' hts as stated above. <br /> Signature <br /> �� , �. . ,��,� ,-.��..,. , � <br /> ,.f /,•�' �i.'�. /."�_� .t'S• � r,:j'�:_w i:.b <br /> �f �'t.� / •i . fi� .� <br /> �.:-'�.�!':�r%�r/ �:'F:� ° t. ' • i ; tii:t� F th.�t'-i•. <br /> �� E.�f.FO��, t�' ,�'� ::}� �.iy�"'(..�'�.i:� <br /> r'������Yid � r�{�'4 ��.j ....'i !1'r �;��� • <br /> 11� � 3� ti C r:.�, ��.. �,.. <br /> � �s ���1 S� w3�;c:i <br /> ���:::;i,•"`%,r r. . <br />