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DATA PRIVACY ADVI80FtY <br /> In accordartce with Minnesota State Statute 13.04 Rights of Sut�ects of Data,Subcf_ 2, "Tennessen waming",we <br /> would lika ta inform you that your reyuest for a permft or lioense from the Cit�r of�rono w any of fts departments <br /> may require you to fumish certain private ar c�nfidentisl information. <br /> You ere nodfied that <br /> 1. The information you fuml�h wf� be used to deEermine your qualiflcation for the permit ur license <br /> requested. <br /> 2. You may refuse to supply data, but refusal mey requlre that the City deny the permit or Ilcenss. <br /> 3. The informa�on may be st�ared w�ith other local, state or federal agencies to the extent necessary <br /> to proeess the perrNt or Ilc��se. <br /> 4. If yo�r requested pertnit or lic:ense requires Counnil action to app.rove, some information may <br /> becflme public. <br /> 5. You heve oertain rights under Mlrmesota State Statute 13.04 (see foBcn�ing page) ta review <br /> private data ort yourseff. <br /> 6. Your full name is required to process this appEication or permlt. <br /> � ��. I�l- <br /> First Mictdle Last <br /> 23����.ot-' w�a 3 a-c� <br /> Address �_" <br /> Mf�V� �1f�tcS Nln� ��� c.�s1•'7�+5 45 t?, <br /> Ciry State Zip phone <br /> I understar� y as e <br /> Signature <br /> R�C�IVED <br /> OG� �.i 2015 <br /> crnr oF oRONo <br /> a�dr.r t�st updar�d: augusr Zois <br /> Page i3 <br /> # 3 7 95 <br />