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DATA PRIVA�Y ADVISO$Y <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, 5ubd. 2, 'Tennessen warning", we <br /> would Eike to inform you that your request for a permit or license from the Ci#y of Orono or any of its departments <br /> may require you to fumish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you fumish will be used to determine your qualification for the permit or Ifcense <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The infarmatlon may be shared with other Iocal, state or federal agencies to the exterrt necessary <br /> to process the permit or Ilcense. <br /> 4. tf your requested permit or license requires Council action to appro�e, some information may <br /> become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04(see following page}to review private <br /> data on yourself, <br /> 6. Your full name is required to process this appiication or�mft. <br /> First Middle Last <br /> Address <br /> C�Y State Zip Phane <br /> I un n my rights s stated above. <br /> ure <br /> RECEIVED <br /> Varienoe AppllcatJon-Januery 2016 MAR 15 201 fi <br /> �e� � � � � C!'�Y OF 4R4N0 <br />