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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 /> �. The information you furnish will be used to determine your qualification for the permit or <br /> license requested. ' <br /> . ' <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 dafa on <br /> yourself. <br /> 6. Your full name is required to rocess ti�is application or perrnit. <br /> t '�S � � v 2 r �-2<��'-z_.� J'1/!�� �ur /�!� Cr <br /> . -� � <br /> First d le Last ` <br /> � s � t �73� ��Zw_� �. . <br /> � fs, Addr ss / Z <br /> ��� �o �`J'���r��°„�� /� /t,/ �"�-.Z�. ��" s.3�-6 �� <br /> City State Zip Phone <br /> I underst d ights as stated above. <br /> � <br /> Si t r <br /> � <br /> � � � ,,....:.::_. ;`' : �r�i � <br /> �;:,_-�>.,, r,;-; <br /> r , �•; ::; i.' ��. <br />� ��t--L.�17 �c:-7 .. . . <br /> ���.� . .. • .. . ' `� • :�.... ,.. <br /> �'�'�.' '�`�; = �..._ �'' �.,.aK._ -_..�;�'�.... <br /> ;:l i ' 4:rzt <br /> �:��':�ssr` � '"��... <br />