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DATA PRIVACY ADV[SORY <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 /> 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. 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 /> MPC'�TI-1� � � Po�l.1FF <br /> First Middle Last — <br /> 26P�o �SA�'c" Rt�j <br /> Address <br /> �o Mt� ��31 �s� ��l c��g <br /> C�ty State Zip Phone <br /> I understand my rig s stated above. <br /> � � <br /> Signature <br /> . ,�. <br /> �^'t � (i � ..�3.:>-�� . <br /> � n f"':.:'.:'•.�i i.'u�t'o',:+' �L:¢ <br /> .� r �`� 1 <br /> C '/� ''1 i;�.� y ' 1 .. '"ia. i���'.ihi.u.'%�;Y�. <br /> n."��i�l.1 : . ...� � ... •' .•` ',-Lf_ "� � <br /> ,t �j �i: � � . J 't ?'I'{ ��� <br /> , Ct�.��j���'�9� •. ,� �' � � � (� .���.,f�� . <br /> !' � .A"i �1��•_'�,•1 j <br /> L'i fl ����dui`..��' ��:.Cis...,c•r . <br /> ,.r�. <br />