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L 7 <br /> . � <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 /> " I � . � <br /> 1. The information you furnish will be used to determine your qualification for the permit or <br /> license requested. . �I <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> � license. i� <br /> 3. The information may be shared with i;ther local, state or federal agencies to the extent <br /> necessary to process the permit or license. . � <br /> 4. If your requested permit or license re��uires Council action to approve, some information <br /> may become public. jf <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 his application or permit. <br /> �.�c,v.'c/ ���"/P�ssf�r� �'I s. /��s�s��� ,`�,yr,s ' . <br /> `iYG <br /> �� • � Mi�dl� /� Last <br /> a �� <br /> A ess I � <br /> � II � � S✓�.�3� Qs�y�'S213v <br /> City � State � Zip . Phone <br /> derstand my ri s as st ab . � � � . <br /> , ` �� . <br /> �� • <br /> Signature <br /> � . <br /> ! <br /> � � � <br /> � � <br /> i <br /> ' � - <br /> � <br /> { . <br /> j <br /> � � <br /> ' . <br /> 1 <br /> � <br />