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. r � <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 that your request <br /> for a permit or license from the City of Orono or any of its departments may require you to furnish certain private <br /> or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent necessary to <br /> process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may become <br /> public. <br /> 5. You have certain rights under M.S. 13.04 (see following page)to review private data on yourself. <br /> � <br /> 6. Your full name is required to process this application or permit. <br /> \�`' ' c a-/� C--' �-/ . <br /> FIRST MIDDLE LAST <br /> �� S�� � <br /> DR SS <br /> ,�-�.�� p� �/ ,�S �,s'� ���� - �� 3- � <br /> CITY �G�p�O � STATE, ZIP PHONE ` <br /> I understand y ights stated ove. � <br /> Sig ur <br /> , <br /> C ( cc.�-�� ;e� � �° <br /> �.�� S5-e� <br /> � <br /> � � �.�. � �� �s�s� �0��� <br /> . ,, <br /> ;� ��c����� <br /> X� <br /> OCT 14 2Q�Q <br /> . CITY OF ORONC? <br /> Subdivision Application Last Updated: January 2010 <br /> 15 � <br /> r. <br /> ' � T�Y • + ' <br />