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�� <br /> f . <br /> ✓ � <br /> . DATA PRIVACY ADVISORY � � <br /> � In accordance with M.S. 13..04, Subd.2, "Rights of subjects of data", we would like <br /> to inform you.that your request for a permit or license from the City of Qrono or any of its <br /> departments may 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 yot�r qualification for <br /> � the permit or license requested. . <br /> � 2. You may refuse to supply data, but refusal may require that the City deny <br /> the permit or license. � <br /> ' � 3. The information may be shared with other local, state or federal agencies to <br /> the extent necessary to process the permit or license. <br /> . 4. � If your requested permit or license requires Council action to approve, some <br /> . information may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review <br /> private data on yourself. - <br /> 6. Your full name is required to process this application or permit. • <br /> ' . <br /> ���c� �1f-ec�.�r�c� �'-�;,,,��5 - <br /> First Middle Last <br /> � � �3� hn;�-b�.�� ���a, <br /> , Address <br /> � vJ r�.� w�� 5�9 1 (�SZ� �-�-5�1-3:5� <br /> �tY . State Zip ' � Phone � � <br /> I understand m ri h s�s-�st�eeHa e:� � <br /> .._. � . ���� _� � <br /> Signature � <br /> . 10 <br />