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• 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. Yau 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. Ifyour requested permit or license requires Council action to approve, some information <br /> rnay become public. � • <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private dafa on <br /> yourself. <br /> 6: Your full name is required to process this application or permit. <br /> �lC:tt�� ��/17 � �/���L� <br /> Firs�`I 2Q � x �Vli�e Last � <br /> � S <br /> Add res <br /> (��i�-�fi �/!,� �S�q( 9'S`�� Ll�3 ���� <br /> �i�y �— State Zip Phone <br /> I understand my rig state above. <br /> Signature <br /> . � <br /> . �` � <br /> , �; <br />