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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 <br /> to inform you that your request for a permit or license from the City of Orono or any o.f its <br /> departments may require you to furnish certain private or confidential information. <br /> You are notified that: " <br /> 1. The inform.ation 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 refusa� may require that the City deny . <br /> the permit or license. � <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 requested permit or license requires Council action to approve, some � <br /> information may become public. <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 name is required to process this application or permit. <br /> (,U�Nt Pra�r�cs , � � � <br /> First Middle Last <br /> � sa 5 0. ��vay-za,-�. �1✓� , �,r�'�c /03 . <br /> Address � - <br /> . w�.yz��� ,�ti -�5� y� ��- �/�5-/907 <br /> City . State Zip Phone � <br /> I understan s stated ab ve <br /> . � <br /> Signature � �,cl• hn�-j, �����, yz,r ��o�/� 'C�ir,� <br /> 10 <br />