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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 informafion. <br /> You are notified that: <br />, <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 /> � � /_�R..�c� A� 'rt�- "e e�„ �,o � v� �� �A�}--o �-�-�.�. �? `-i��-'�� s <br /> First Middle Last � ' � ` � <br /> -Y C�2.\ �T ���y' � <br /> Address ' <br /> + �1. ��s�'v�.� �Q�� M�. \ n � <br /> �'�i"T�—�'l �iS� `�cS`I Z''�°L�- <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> ,� <br /> Signature <br /> �,�� t t�'�� �fi ' <br /> � ��; ��'' ��. � <br /> _i�-f-� �J �"� ,.1 .� h�...; p � <br /> ' ,T�I l� `'r � �1 J (�f 4 ( �� +�:.s,i� �' �.. <br /> ;� ,s ,� r 'r <br /> r��l i!`-i{�'"9 � ��S. .,��„ .� - a:�t /�� . <br /> '`t�/'hti ��z. !.' � � ' F y�� . <br /> .L�f.f l "'c." r f•�''� V � <br /> , �:'r,!3. `�r;�..-�r� � , <br />