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� / , <br /> DATA PRIVACY ADVISORY . <br /> In accordance iivith.M.S. 13.04,�Subd. 2, "Rights of subjects of data", we would like <br /> to inform you that your request for a permit or license from the City of Orono or any of its <br /> depar�ments may 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 quafification for <br /> the permit or license requested. � <br /> 2. You may refuse to supply data, but refusal may.require that the City deny <br /> the permit or license. . <br /> 3. The information may be shared with other local, state or federal agencies to <br /> the extent necessary to process the permit or license. . � . <br /> 4. If your requested permit or license requires Council action to approve, <br /> some information may become public. . <br /> 5. You have certain rights under M.S. 13,04 (see following page) to review <br /> private data �n yourself. � <br /> 6. Your full name is required to process this application or permit. <br /> h i`-t�r�CC i^i'Gk �P('��Ct.�, !ii �f'r�C'i��� /l�r,�z,� <br /> First Middle L t <br /> ' __��( :�R�� �c�- �/ � <br /> Address <br /> ���,/S�� �'�l/l/ S�S�2 z 7�� S 3 5'.��,yi��`r� <br /> City State Zip Phone <br /> I understand my righ s as stated above. <br /> • ..j . � . <br /> Signature � � � <br /> � � �,,, _..�> <br /> 7 � �� 1,� �� /�✓ w� ���� <br /> �_,�< �<rj� t�° �i: �j'j 4;,: r� a <br /> r 1�:,, � �;y.� ,x tn: , <br /> ��' (� ��f w,�,:.� �r <br /> ����CLyaS7 G���Y .p.�r `c�.•.21. i.r <br /> ''"����,}�i'�'a �l "ti'`t <;n:�w� • 4::; > <br /> ��� �,.��j �+'''`,. . �� ���;�:;- ':� f,4y .j� u� i� <br /> ( ���{�}_..•7; �.N '�s:�.ui `�C•i:i�i'lidtt? ~ � <br /> t ;.�,c+:`:'• `�'r'�i»a> C51", <br />