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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 anjr 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. lf 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 fuff name is required to process this application or permit. <br /> J oh►� � �-lo I I p�d.�� <br /> First Middle Last <br /> Za� -�-Eoll�v�de,� �.o r-�e�� <br /> Address <br /> UU�c,z�a�- VY�►� 55 3q ( (p IZ �2�f(o-9 I5� <br /> City State Zip Phone <br /> I understa m ights as stated ab e. <br /> Si atur <br /> 4i � l� , ,� � � <br /> f�'��� �•» �i ,� ri``y �r,t;�`�'' o:'� 'Y� <br /> �1. yir„ �";� t�4�, ,�`rs ,c;;F�.,�; „� }�. <br /> L�1^r'6 �� `.:.;. ,,. Q� <br /> [I.':- � � j i�r"nt � <br /> � ..%5: �'�.. • . ..?::i?'�'1,.S ;�� ,`��t! <br /> � � r:. j; .1 �._t,.�� <br /> "' `, -.���'�°' � ��'iJ �`'T��.�..... (`�}•7'`'{G�:.�+.�"� <br /> `;�v _ <br />