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r t <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 that <br /> . your request for a permit or license from the City of Orono or any of its departments may require you to <br /> 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 license <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent necessary <br /> to process the permit or license, <br /> 4. If your requested permit or license requires Council action to approve, some information may <br /> become public. ' <br /> 5. You have certain rights under M.S. 13,04 (see following page) to review private data on yourself. <br /> 6, Your full name is required to process this application or permit. � <br /> fCE'R�v M. .�S/oPP E <br /> FIRST MIDDLE LAST . � <br /> L/75�.5- (.'/,/A�'J.11u/uOD �P Da D �GUJu/TE< /Z F1'JD F,v C G� <br /> ADDRESS <br /> Ci1�zE' G�l/ 5�1�'L/ 7/5�79�� ZL1.��/ <br /> CITY STATE, ZIP .PHONE <br /> i understan y rights as stated abp . <br /> / � <br /> Signatur <br /> � ,� -� ;, .�. <br /> . y,hl rJn ^�y' + F �. , 5 �,3� . <br /> �lM1S;S �, + ) 'y) <br /> ����� � � <br /> - 14 - �" �;�.� �i�::��.��"� � ._.. `� � � '�;.y;�'� . . . <br />