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. _ - _ <br /> , , . . ., <br /> ;z <br /> . . , <br /> . . . <br /> ,, _ . <br /> , � �ti <br /> . , . . .- , . . <br /> . ; .._ . • ; . ., _ . . . , ,F <br />. _. : _ . , . ; . : _ . . . , : - w -: <br /> � . �DATA PRIVACY ADVISORY . � � <br /> In accordance virith M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you �f <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 /> . , . . <br /> . . . _ . <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 /> . " 2. You may refuse to supply data, but refusal may �equire 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 /> . . . �w`.e� : �.ol�tv-� � VKo�2k�S <br /> , First Middle Last <br /> ' : I Z�o i ���� ". ('�� _ . . <br /> Address . <br /> . . . <br /> . ��.vwsv�lt� _ row�l s�s33� g�z-Z92�-«�73 � � <br /> City � State Zip Phone <br /> - I understand my rights as stated above. - . ,. <br /> Sign t e . <br /> .,. . � . .*. <br /> : . � � . � �� �� �r� 4,, ; . ` . <br /> �r7 !, <br /> . . � . .;,�"s% �._.-.�::t�3 � Y � <br /> � [�-' �-"as� � � <br /> . - ' . . . ' . . .. � � � � t��'. f'n�ry•r r�� . . . �.� �p . � . . . <br /> ! l �k��) '�'�l A <br /> . . . �t.p L 3�n.1� . . <br /> . .... .._ . � . . <br /> . „ ��. ....�:. � .�.�. .. . . .". ._.". ...-..�.. .. �. . �. � - .. -.»r.,-.. .. . —+,-, -. _. ..xT.. .. r.,.-- r- . <br /> . . . , . - . . � . . _.P-..:. �. . - . . . _ .. - .. . .. , . ��HS�+��. . . . - <br />