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rL(1 LL VV vv• ....�+ � - - <br /> . DATA PRIVACY ADV150RY <br /> ln accordance wlth M.S. 13,04, Subd. 2,"Rights of subjects of data", we wauld like to"snform yo� <br /> that your request for a permit or license from the Clty of Oronv or any of its departments may <br /> require you to furnish certain private or confidenti�) inforrnation. <br /> You are notified that: • <br /> 1. The information you furnish wi11 be used tv determine your qualifi�ation for the pormit or <br /> license requested. <br /> • 2, Yau may refuse to supply data, but refusal may rEqulre that the City deny the permit ar <br /> license. <br /> 3. The informatian may be shared with other locai, state or Eederal agencies to the exient <br /> necessary to process the permit or license. <br /> 4, If your requested permit ar license requires Gauncil actian to approve, some information <br /> may become public. <br /> 5. You have certain rights under M.S. 13.04 (se�following page) to review private data on <br /> yourself, <br /> • 6. Youf full name is required to process this applicaiion or permit. <br /> �l-��.v� }�iui►� �-c7�;� <br /> First . Middle Last <br /> .`{3� G�-vr� �(�.c� (�12-3U��'-13�?� <br /> Add ss r 1 /�v �s � <br /> State Zip Phone • <br /> City • <br /> I understand my rights as stated above. <br /> � � <br /> Sign ure • <br /> ..��:1 ,,,'y�:��i <br /> �� r <br /> . �� �a�, 6S �'.'.,_ ''�_ �}�� .r' <br /> � �. . . �yyj� <br /> .� 'i �:5.. ��;�.,: <br /> t��; �: ' ' ''.E.::�w, 't � , <br /> L';; �.;. •.4..; t^t <br /> .l�i . , '•j �r�i1,J <br /> 7!?3r-yit'r,'.!;<:Ei: �„ .�i:� 't��• ��.;/ <br /> i17 }7 �?;�.� �A ...-. ".:,' <br /> t�.� �r ctx:._.. <br />