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• J, 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 departments may <br /> require you to furnish certain private or confidential information. <br /> You are notified�hat: • . <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 /> :. { . . .. . _. . . .. . <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 /> �A�3 l� �J � � `��CLf� . . <br /> First � � � � Middle Last <br /> 3Z� ���40�,1Jt�� � LA�►.�� ,_ .. . . . <br /> Add�Cs��l.QV i� N(1.� _ 55�1 (o l Z•Z4-1 •�-5^1"1 <br /> t� <br /> City State Zip Phone <br /> I under tan y rights state a ve. � ' � <br /> . <br /> Signature � <br />