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DAl'A PRIVACl'AD1/IS41�Y • <br /> In accordance with M.S. 13.04, Subd. 2, "Righfs of subjects of data",we would like to inform you <br /> that your request for a permit or licens�from the City of�rono or any of its depar�ments 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 refusaf 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 ac�ion 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 �equired to process this application or permit. <br /> �4�11'�..�L" V���I.�C\ �I���6Jti�s�•a <br /> First Mi�idle Last <br /> y 2-z.s �-r`>�--�s-►- Lfr/�z. ,1.7,��r-�. <br /> Address C'"',,�` ,�r� /�'�l`l S S�.-3 � �f ��S �f 7d f.l� <br /> � �� � <br /> City Stat� Zip Phone <br /> 1 understand my rights as stated above. <br /> , <br /> Signature ' �`� <br /> -- �:�,>, , <br /> :� ,::s--•�ti " -•.� ::%'��': <br /> '�'�. �;�:� <br /> 1.;, ,, •r� <br /> , _ _ -. _• . . . . f�.;% <br /> , . . `; <br />