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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 confidentiai 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 suppiy 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 /> �� � � � �G ��,� <br /> First r � Mid le Last � . <br /> ��I ��..�--'T' �.'��� �'��---� � ���� <br /> . Address � . <br /> - � ' � � �-e-� ��c�Z.. <br /> City State Zip Phone <br /> I underst m •ig s a stat bo-„a ve. <br /> �-- <br /> ., ` ------=-_—_.. <br /> Si �tur ' <br /> , <br /> �' j,�;s.:��+4 �.! �,, ft.,. F+��:a..{� <br /> . ,�%� '41 �-� �(' i �� `,� (r J%"e�;s:�Gl � <br /> - �� (/��, • +/ �.'`^ ..i� � y�) 1� <br /> r�"a.�^'� �'1� -.C�.J`jJ ��/ ��:� <br /> �`Jj` �{r �m: u� T c3<'I t���� <br /> f� c' �''.a � i�� 1 ,� <br /> d �S!m "�:w 1-i%` G:f�L.F„:i.1r �'ti� � <br />