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DATA PRIVACY ADVISORY <br /> ln accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like <br /> � to inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or confdential information. <br /> You are notified that: <br /> � 1. The information you furnish will be used to determine your quafification for <br /> the permit or license requested. � <br /> . 2. You may refuse to supply data, but refusal may.require that the City deny <br /> the permit or license. . <br /> 3. The information may be shared with other local, state or federal agencies to <br /> � the extent necessary to process the permit or license. � <br /> � 4. If your requested permit or license requires Council action to approve, � <br /> � some information may become public. . <br /> ' S. You have ce.rtain rights under M.S, 13,04 (see following page) to review <br /> private data on yourself. � <br /> 6. Your full name is required to process this application or permit. <br /> �n , � <br /> I� l� i �(+��.�� �Q�1 � c` ��Sa�n <br /> First Middle Last <br /> � �a�� ��.���.� ��� � � - . <br /> Address � � <br /> � � 0 i�C� 1rn t� �5��31 ci��—Ll-�/-- 7s`�0 <br /> City State . Zip Phone <br /> I understand my rights as s#ated above. � <br /> ���� 09�,� <br /> Signature . � � � <br /> 7 „ f��`<t- A.w��k� ��i:�^ ��:"�T..'' �� 1 <br /> [� .j.�t` f�'� t' <br /> �G�� �� ,r�.) i;� � , �:. . .. ... � �� <br /> f � <br /> E��':,,—.;:,, �.; ... J �s.. � <br /> `�• c;� ` •' <br /> . , 19��1P�j�.�y:'Y � �;�.;'� � •�� �..�.. 1s� �•'-:t ��) j : <br /> �� 7"./ . �.�J` �j' �....-. ....,"�%� <br /> a� �:Q'".:u. <br />