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pAIA PRIVACY ADVI$Oi�Y <br /> In accordanoe with Minnesota Stste Statute 13.04 Rlghts ot'SubJects af Data, Subd. 2, "Tennessen waming',we <br /> would like to inform you that your request for a permit or Ifoense from the Cit�r of�rono or any of fts departmenb <br /> may requ�re you to fixmish certain private or confiden#ial information. <br /> You are r�otified that <br /> ?. 7he information you furn1�M wf� be used to determine your qualiflcation for the permit or Iicense <br /> requested. <br /> 2. You m�y reiuse to suppy data, but refusal may requlre that the Ciiy deny the permit or license. <br /> 3. The informa�on may be�ared vwith other locdl,state or federal agencies to the extent necessary <br /> to pnocess the perrr�t or 1tc��►�e. <br /> 4. IT yo►�r requested permit cx lic�nse requires Counoil action �o app.rove, some information may <br /> become public. <br /> 5. You have certain rights under Mlrmesota Stete Statute 13.04 (see fo�c�ring page) ta review <br /> private data ort yourseti. <br /> 6. Your full name is required to prooess this appfication or permlt. <br /> l �,V.,cS�Cl��{ IJl' r�u.-�� <br /> F�rst 'T Middle Last <br /> 234�3 t��.o�'- ,r.N o a p-c� <br /> Address ' <br /> Mf�t� �H�1f�ttS Nl� ��2-o t,.tsl•��5• 45I� <br /> City State Zip phone � <br /> I understar� y �s , -e <br /> Signature <br /> R�C�tVED <br /> OC'� �.i 2015 <br /> C�T1(OF ORONO <br /> �.r ia�r upderea� au9�,s�20�3 <br /> Page 13 <br /> # 3 ? 95 <br />