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. DATA PRIVACY ADV[SORY <br /> ln 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 /> ° '� t;L' � �� �-�. " � � � . <br /> First Middle L st <br /> � . <br /> ddress <br /> ' j ' � � ' ' T � � � <br /> City State ip � Phone <br /> I unde my rights s ted above. �� ' <br /> " � ---�. <br /> Signature <br /> r�,�� ;� , <br /> . � .� tc�.l^, r%-:,-..,,� r c. <br /> .Y f ,\ ir%` y <br /> �. ��: '.� ,:.-., �;i:.,.�., �;� <br /> 4,�Y'�q '.,,' . .�ri'� e::': .:: — _.., .c�;� <br /> � `., �=::�. :,;;;: �•-_ ' �•�::;�i..t !? <br /> �,:��7S/�����:,v ;;�, . , .L `,i '�`� '� <br /> • � 6� FJ C�,) . � .... • . �y�� <br /> ��`'�;?;",y'=�"'' 6% '*.'...o: .,,`�Y�Y <br /> � <br />