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, DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd, 2, "Rights of subjects of data", "vue 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 /> iicense 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 federaf 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 /> Gd'S�l�G��s <�G!l P�� /'�/ +�/t/� �O k <br /> First / Middle��--� Last <br /> / S'.��?o���iY�i� C��.�, 'v �- '`�/-30 <br /> � Ad�ss ��:v /f�� � /� ��3�7 �52—���gJ�$� <br /> City State Zip Phone <br /> I un rstand my rights stated ove <br /> . , <br /> �� � <br /> Signature <br /> �,,��� ..� �.�., <br /> . r���,��..x� �G�c,. .�:; r ^''i;. �f�� �;•p, � <br /> � ;�=•' t,�� i.i �°'� `•wi�s�;;- <br /> ,.W~;y.:7� .^ •�:C�:� ,,?.�� (��j �,��:� <br /> ��'�/ � f� ���..� y �;�" rn":"�; <br /> �,.,r.�� i •�,"-�f � ��`y .,r,;:; <br /> '�"��...-�t• L�� i�l Es� .:'.Sr) <br /> •�:'�STa'rJ� SLt�+�•:•'f <br />