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� . ,. � <br /> DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br /> warning , we would like to inform you that your request for a permit or license from the City of Orono or <br /> �� <br /> any of its departments may require you to furnish certain private 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 <br /> license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny 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 Minnesota State Statute 13.04 (see following page) to <br /> '�� review private data on yourself. ��� <br /> . 6. Your full name is required to process this application or permit. <br /> J�c� � �f,�-cC,�`�.S <br /> First Middle Last <br /> /S`ii.� ��` a���J vc�d , <br /> Address <br /> p y�o,�-��- �;�� ss��.� ���Z� �S � -S��-� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> � � <br /> Signature <br /> ��CEIVED <br /> �'�B 2 2 2012 <br /> CIT1(OF OR4N0 <br /> CUP&Other Land Use Applications <br /> Updated: January 31,2012 <br /> -15- <br />