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i � <br /> DATA PR{VACY ADVlSORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like 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 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 refusal 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 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 /> �P�t � ��(\rn��-�� ������`T�-v�-� , <br /> First ^ Middle Last <br /> �� G(��tL��lc�. �.-.,� � <br /> Address � �- �/V .�.s-� �� �/�-�Sv'-��� <br /> City State Zip Phone <br /> I understand my righ�s,stated above. M_ M _ `Y. . . <br /> r`/,,��//���-� � <br /> Signature (/ � <br /> �., <br /> :-�� : . . . <br />