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- � � . � DATA PRIVACY ADVISORY - . ` � <br /> ,1n 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 /> . . . � � <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 oc license requires Council action to ap.prove, some information . '_ <br /> ' may become public. . . � � . �. . � . <br /> 5. You have certain rights under M.S. 13.04 fs'ee following page)to review private data on . <br /> " Yourself. � - <br /> � _ 6. :Your full name is required to process this application or permit. . � � ° <br /> . . -�o �(�'� � . . �: '��C�C�s7��� � � .� . ` <br /> ' First � Middle Last <br /> . �5,�-l°1 �'L�.-�����1�27_�. ' . . <br /> Address � . . . . <br /> � ��,t�i,��'c� �f����- l�C�C�'9-f'?`5 i� J`"l-� s`S"��7C� Cr��2�.Z5c�-�1��� <br /> , . City . , St�te Zip Phone . <br /> I understand my rights as ,�tat d above.� . � <br /> ' �/ �� c ----____----__...�.,.�_`� . <br /> Signature '-`� . ,� . , � , . <br /> . �.: . _ <br /> � . : , _ <br /> � , - ; . ,� , , . . <br /> ' . . ^ ' ' ' . , � . . . .� . '� . .. . ...h' . . -� . ��T ' , . � ' . . <br /> - . . . . .. � . ��'� �}+�4 � •�f . . ' �I� � ,``; . . . t . � . <br /> � • ��• , �„•' � • � .d <br />, - � . . ' . ;� � • :�.�, �. :1.' '��_ ��1 . . � _ _ . . .�J'+', ' p F .. <br /> �� � <br />