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1 � i � <br /> Itenr#11-CC Agenda-12/11/06 <br /> File#06-3234/35[Total Pages 94J <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 that: . <br /> �. 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�ieny 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 /> 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 /> GS'S ��G-��s �G!l Ci���J/'i/ t°/V� �0 L`'��. <br /> First / Middle��� Las� <br /> / �,�ff�p'"G-//S'�/G C__�l'+i V '�— /�� ' <br /> Ad ss �� �,/ �/ <br /> ��D�i:5r�. /f�G� � � //Y J ���7 �5 Z�p/SJ �`$ <br /> City State Zip Phone <br /> I un rstand my rights�a stated ove <br /> . � , � <br /> Signature <br /> y.5���' y��.�...��: ,.,F`��.;� <br /> F� 1'.!� a ..,.•�•.' S�: `�'+.. $T� .rv <br /> ���y�4y,:;j, �.:;�,�� ���� t,s� �� y��,� _�..Lu,:; <br /> �✓ i : �'� ��i✓ <br /> �` �.. lj}�'��"' .y'�Y' .:t7..�•��• <br /> � t'� f::� (±ii�• ,�� ,+� ��`.�f •.. <br /> �w:ar�- s :��`'�.'.'.'.tirl �� ��4� E,�� ra'i <br /> :.+,.-au'• a�T,..�:s.:rr . <br />