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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 confidentiaf information. <br /> You are notified that: <br /> 1. The information you furnish wil� 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 /> � � �-�--� � - � ��: <br /> Firs�� ��� Middle L <br /> ' G�w� <br /> Add e s � <br /> .. �����, ��,._.._` ,��� �`� � � � � �,F � �,� � <br /> City State Zip � "Phone�T � <br /> I understand my rights as stated above. . <br /> . � � �� � <br /> Signature ' <br /> . p''r"s��Y"' '`,,•�'�;r�' �; �?t `i��� . <br /> �F �k�� �;,. ':? "�"-'�� �; <br /> ���,�� ,� •} � ',,'' f''" <br /> � ,'�',' ' ,t�,.� i`,� <br /> F�{ � G r.,.;,::, x���<<,.= � <br /> �f �� �� �� 4y', .r �`j: �I. <br /> t`4 �, �.:.�k,�,� 6,,,•, <br />