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' . ' �, f <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 departmenfs 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. <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 ful.l name is required to process this application or�permit. <br /> . . ........;_.. _:_... .�_ _, . . � <br /> . ...�._._. ..... .... . <br /> .e.�c�, � <br /> . . . ..._..._. . . . <br /> � . .�P.o��s � . .. . <br /> First Middle Last <br /> ��'� �'c.o.-� �-. <br /> , Address <br /> F',c�y;�caz I'�� 5533� ``�Z. 1�-�k�k• �121 <br /> City State Zip Phone <br /> I understand my rights as stated above. . <br /> Signature . <br /> . .w�.� s;.a.q ;n:,....� �/.:,;�, �-i � <br /> ` c� <br /> �''� � �� . � . <br /> . �i'ML �.�1� �(M� ��?11My � ' . <br /> JN <br />