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.,c <br /> DATA PRIVACY ADVlSORY <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 /> 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 /> First Middle Last <br /> , �g s a t� C�� a a �'00. � . <br /> Address . . � <br /> ' Q✓�o� �.� S��S-� �'SZ-�'y��8�b <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> �_ ~ <br /> Signature � <br /> RECEIVED <br /> FER �4 2012 <br /> CUP&Other Land Use Applications � �.rITY OF ORONO <br /> Updated: January 31,2012 <br /> ' - 15- <br />