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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 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 f�.ave certain rights under M.S. 13.04 (see following page) to review private data on <br /> youfself. <br /> . 6. Your full name is required to process this application or permit. <br /> � <br /> � G�-�'i i�t �i 4�ft�� .� 'y jt��1`i � <br /> First , Middle Last <br /> � ��� ���i� fP1f,��� ��w���, <br /> Ad��'���?��4� I �P�eta� ��� � ���� � (c�l� "�i���' �`����� <br /> City � � �` State Zip Phone <br /> I understand my rights �s,stated above. <br /> �;,,�',✓.�-�ts'b'"t/'` i9a ' �}�1 dlfa"r}.:�;'s�a� <br /> Signature ' � <br /> . �;�..,.,, ,�;;� <br /> ,�;��� a� ��.-v, f�' + <br /> `���y" �... ' . . =h ..- . :I • .. �,�f <br /> xcz�,�-,�i<,�;e'�:r � • ' °�'. t.,,� ' r ,� r <br /> r ::�.,.vs��":��� <br /> �}F� ;....-_ . u -.�.. �'�t.��.i;itii�`` <br />