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,_ �� <br /> �. - <br /> . DATA PRIVACY ADVISORY � - �� <br /> ln accordance with M.S. 13.04, Subd. 2, "Rights af subjects of data", we would like <br /> � to inform you that your request for a permit or license from the City of Orono 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 your 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 (icense. . <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 requesied permit or license requires Council action to approve; <br /> some information may become p�ublic: , <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 nam� is required to process this applicatiori or permit. � . � � �� <br /> . 1�"Z�v1� 1���1 c, ��1 �Gc�.Sc�� <br /> � .. � � First � � Middle Last � � . <br /> ,• . ' �� —1 1 r�'S'1 l_!�'� ���c�\`��C� 1 �l�`-)� � . . . ' <br /> . � Address " . � � . � � � <br /> � � �N ����L,� � �� �5�� �,2- s9�- 835�� . <br /> . � � Cif� � StafE Zip . Phone �� <br /> _ � l . <br /> ..� � -. ( understand my rights as stated above. � � <br /> . � <br /> � �' � J ( � ' �� `b�' . <br /> ' �, Signaiure <br /> �:,. �; .___ <br /> . , � . .,, :. ,t�:--.�,,. <br /> . ;;;� ;;� <br /> ; . . . ,:'� � <br /> . : � � .. . .. .... ,... ,, ... .; <br /> . . :'�� .;; •• •.._..., r`' ...� =' '•�-�-ti=�`' <br />