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• . ` <br /> 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 /> 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 p"rocess 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. Ybu 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 pe�nit. <br /> �/d��-1��c—� . ���.�/--/i <br /> Firs� Middle � Last � <br /> f dl�O ./���� .�0�.�� <br />� Address l <br /> /���c7/V� /�/� ����� ���� ����/�es�" <br /> City State � Zip � . Phone <br /> I understand my rig t�s as s # above. <br /> �.� . <br /> _ Signature . - <br /> c� s� ,: �:'... '� e�a�� <br /> �; i• :1 ,:.ti. C.' .... �:`, , <br /> ' ;� : ��:,� <br /> nif'd. :,; .�� ... ' i' ;' ..•, <br /> , . ,i' :r .. . <br /> � ��Y` �;'-. " . .. �,,. " ���;: <br /> , t3:�1.� Y.' i ,' :ii l;..• �.. 9n.', ,. <br /> �a .1 �'. �.:' 'j �,.`,ry;�, t_.i:�f:itiiii <br /> .G'; [J •tiv';C.:. �� ...... <br />