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i <br /> � <br /> � . <br /> � <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we wouid 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 confidentia{ information. <br /> � <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 /> i <br /> 1� 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> license. � <br /> f <br /> i3. 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 /> I <br /> I <br /> ; 5. You have certain rights under M.S. 13.04 (see following page) to review private data on <br /> � yourself. <br /> 1 <br /> . � 6. Your full name is required to process this application or permit. <br /> ; � . �. <br /> P �� <br /> � ,,� �v�1 ./�- <br /> '� First �-- iddfe � Last <br /> ! . l� ( �� .� <br /> ! Addr s� j , � <br /> : l� � �/ .� � � � � Z�� <br /> City State Zip Phone <br /> ;` <br /> I underst n ", ;i �i.ts � at above. <br /> 1 � � � ° � <br /> , ,�.., <br /> Signature � � <br /> � <br /> i <br /> , <br /> i <br /> i <br /> � <br /> i <br /> I ` r "'�cs. .Y�r..._�;��7 �t � <br /> 7� {: � �'i E� <br /> ��, ��''� � � � <br /> �, � t�.: <br /> � � � �:; ;:��- �����., � ., <br /> � . �:.�:.. .•.•s�'' . t�;.�� � <br /> �r:r�-,�5-�t;.� �:,�, a.• r_, <:� �' <br /> i �' � � y� G`:� tl �:': w. y <br /> 4 'Ei ,f. <,•V��.G�$ �a�:i:,^Z,`,'�'✓r� 47F:•`r��"'..£'1 <br /> 31::Z'S'• ��'�"'� . <br /> � <br /> I <br />