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. � <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 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 /> f icense. <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 /> - � . . - - . _ . . . <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 data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �Av�t� �.J . , ,:��CLf� -. .. - . <br /> First � � � � � Middle Last <br /> 3ZS� �t�S-�O�I�i�-�.J �a,-�..�` ,. . . . , . <br /> Add ess <br /> � f����n.o�;�l n�t�J ss4�-1 �tz�Z4`1 •�s�� <br /> City State Zip Phone <br /> I under tan y rights state ab ve. � � . <br /> , . <br /> Signature <br />