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DATA PRNACY ADVISOEYY <br /> In accordance with M.S. 13.�4, Subd. 2, "Rights of subjects of dafa",we would like to inform you <br /> that your request for a permit or license fram the City of Orono or any of its departments may <br /> require you to furni�h certain private or confidentiai information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification forthe permit or <br /> license requested. <br /> 2. You may refuse to supp(y 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 federai agencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Cauncil 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 /> j �hv1�e.'�'� �e.�cL�c�. �'Y1d�i"�atJ <br /> First Middie Lasf <br /> y2zs` �^��+ L.4-l�- ,Qr;�-� <br /> Address ���3 s��. �� 5 5�...� � �'� ��S z tf7Z-5`��G <br /> City Stafe Zip Phone <br /> I understand my rights as stated above. <br /> Signature <br /> r+*� ve'� t }; � `�Y�� a'� ..: -�� +�� h�. � <br /> l��� "�.� %�c,, i ��: �y� kti� !,� � <br /> 1� —�4 �Y�f � 1 j� ��� <br /> /`3'� �?'a �� �} 1 �'���� ..��� �t+ �{;� . <br /> '�:'�r�—�- L ��"r:� °�•••� ' �"�"�_"''� <br />