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DATA PRIVACY ADVISORY <br /> In aocordance with Minnesola State Statute 13.04 Rights of Subjeds of Data, Subd. 2, "Tennessen warning", we <br /> would like to infwm you that your request for a permit or IRcense from the City of Orono or any of its departments <br /> may requirc you to fumish certain private or confideMial information. <br /> You are notified that: <br /> 1. The information you fumish will be used to determine your quaiification for the permit or lioense <br /> requested. <br /> 2. You may refuse to supply data,but refusal may require that the City deny the permit or license. <br /> 3. 7he information may be shared with other local,state or federal agenaes to the extent necessary <br /> to process the permit or lioense. <br /> 4. If your requested permit or lioense requires Counal ac�ion to approve, some informadon 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 /> fi. Your full name is required to process this appiication or permit. <br /> Robert Jerome Gumnit <br /> First Middle Last <br /> 1100 Old Crystal Bay Rd S <br /> Address <br /> Orono MN 55391 612 747 006B <br /> City State Zip p��e <br /> I understand my rights as s ted above. <br /> l <br /> �� <br /> Signature <br /> CUP Application—January 2016 <br /> RECEIVED <br /> Page 8 AUG 15 2016 <br /> � � Q �� C1TY�F ORONO <br /> 0 <br />