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� ' <br /> �� DATA PRIVACY ADVISORY <br /> , <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 /> t - <br /> 1. The information you furnish will be used to determine your qualification for the permit or <br /> � license requested. <br /> C; � <br /> • 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> � license. <br /> ". 3. T e ' o afo a be s wit ot e lo <br /> h inf rm t n m y hared h h r cal, state or federal agencies to the extent <br /> necessary to process the permit or license. <br /> ` ' 4. ff your requested permit or license requires Council action to approve, some information <br /> , <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 /> -� . <br /> l_; 6. Your full name is required to process this application or permit. <br /> , �J <br /> "' _ ��� ! . � 6r,rn�'��� ��Z,��v�-- <br /> � <br /> � ; First -� Middle Last � <br /> C�(� G���fu��l� t'�i,r� � <br /> ' Address � 1 � N ��� j� �/���v•��� <br /> ��; � �-�. � <br /> City State Zip Phone <br /> I understand m ri s s tated above. . <br /> f:� y ; .�_ ._._._._...._.._.. . <br /> , � � � � <br /> Signature �/ � <br /> lLL: . . <br /> L.� . <br /> , <br /> L� <br /> �;;, <br /> l.._. _.. , ,. r.. . . . , � . <br /> ��� . . . R.._ r} <br /> ��•,f� ��. .. . . . , <br /> �..J . 15�.+'j' ...... .. - �.. . <br /> . .�I L' . . � . <br /> �'' <br /> ! � j <br /> l�.i <br />