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, . <br /> � � <br /> � � <br /> t� , t'sr .� , <br /> r <br /> � <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 fihe 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 dafa on <br /> yourself. . <br /> 6. Your full name is required to process this application or permit. • <br /> . . ..._..,_.., .:.... . ... .: . . <br /> . ....._._. ._... .. . <br /> .e�c�, � <br /> . ......._. . _ . <br /> � �P�i-o� . . <br /> First ' Middle Last <br /> ��'� �c�� �-. � <br /> Address <br /> F" �y,�ca I'�� 5533� `��Z. �-��k•��21 <br /> City State Zip Phone � <br /> I understand my rights as stated above. <br /> Signature . <br /> ����M� .:.,<:� �:.:: � �,;,,. �;; <br /> a, ,, � � <br /> ��i� �. f �; �"y� � <br /> ���'O{ '�� � S . . <br /> .:.�, 'a1rr <br /> \ <br />