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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 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 /> ��`�U f�TC/tJ� y�' . <br /> First Middle Last <br /> �. �-�� s�fr�a y ���h �� � <br /> Address <br /> n 4�o N(� l�-1 l�/� �oS'-- 3 5� - ��5� <br /> City �/� State Zip Phone <br /> I understand my �(ghts s stated ab v . <br /> Signature '� r <br /> � � ��� ���:'K�, ;^—",.�:;;:�,,, ,��'`�>;� , <br /> r-�>,if:.� ��.;: y 4;:� ,'•'�,ry. r:�::' ., <br /> u y >� :�� 4�. .",, ::, ,,:. <br /> ."L�e .`f ..J. " . ._•y:i'.. 1 <br /> �., r : .. .. : ..� .= .. ,.. . <br /> �'a2',1•:�: !� ..r ..` , �' ,� .,' ' �j 5y�i <br /> � �� ;`�+ •��, � ..j.. 4:'i �� ,n��.��tY <br /> _;,��.r `�.y:.-��� a <br />