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f� � ' <br /> �.. . <br /> DATA PRIVACY ADVfSORY � <br /> In accordance with 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 /> departments rnay 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 <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 on yourself. • <br /> 6. Your full name is required to process this application or permit. <br /> �c�r� - <br /> First Mtddle Last � <br /> �7 ,� � <br /> Address . <br /> __�,����o ���,�/ ��33/ � �/z �99�7�7 <br /> C�fy Stafie Zip Phone <br /> I u der a d r� `rig ts,a stafie above. <br /> . � �. ,. `,� � <br /> Signafu e . <br /> 7 .� r"`�,��,, , M1 f,�- s�, �� � <br /> ��'? F ��`k. f (���� ;F5`•'� °� <br /> ���--� ;� �a� �� f��l s'� . '' � <br /> �� . L: <:.�� '" ` � .� t...�..�., , <br /> �L �� .�� `� ��« 7 s_;:. t YYY r <br /> �' ff •� ,IJ,� �"'``?y,:��xy:✓! V�>:".l c—��;'.%r�' �' / <br /> , �tZ�c..�tr <br />