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� DATA PRIVACY ADVISORY <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 folfowing page) to review private data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �r7���'I �/��i-���� ��fv�z . <br /> First � /� Middl Last <br /> ' S �7` � ✓� �c�� <br /> Address r <br /> i��2-���� ��� -����� 9sz ��� �-,�.�3 <br /> City State Zip Phone � <br /> I understand right �'s sta� above. <br /> , / , <br /> Signature ' <br /> . {E.;,! ,�'s`��`� <br /> i r j ;�µ t'i �^�y_� `� � 5 . <br /> � 1 ��, � . , �.., ,,.+��,:� <br /> ''-/,j��� � , ;;:' r���r ,, ��:� , �<��..r,.:, <br /> IJ;, �. .�':1 f: 'y`_'J �:•��.::::. <br /> yr :!7 i <br />