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l' _'�� <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. F � � <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 /> A �/(►�.(,t,t�s p,P/!�1� � � �/���,�J ,E�1��1t',}� <br /> First � dc�l Last <br /> /°�S� �`�� �, . <br /> Address � . . . . .. .. . . . . . . • <br /> S�/ --(t��'o�., <br /> , City State Zip hone <br /> I understand my rights as stated above. � � � . <br /> ���GI�,C/�,�/ F/Y'�3,�1/Yt/ � <br /> Signature � <br /> ... � , ' .�t � . P��: . . . t� . . . . .. <br />