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7 � <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 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 permit. <br /> '�:��,�.�� 1Zo1�t�;-� IMo�L&�� <br /> First Middle Last <br /> 1'2�U i .1�i:.�-�� f�Sr <br /> a <br /> Addr�eJss <br /> TJii�.VVISV�eI�_Q VY+V�F °r'✓'�J�3a�� �J�L�'✓�/�'�f�� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> ��.. N/L�°—",�.�-- <br /> Sign�t�Ce <br /> �..� <br /> , -,�,. <br /> G�ap��'J lJ �� c� {f t1 � �� �� <br /> l t �� � i '�'t� I. <br /> �3~� r i rt . � s <br /> G..^,v �'7 �` s '" • t ; ;:) � x' � <br /> �� � � , , �� rf �'�� ���' h <br /> �) 3 f �/ ...�..y �7. ��.h"l 1`�,�,'�}� Y� <br /> c.:.,.. !. _ <br />