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DATA PRNACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen waming", we <br /> would like to inform you that your request for a permit or Jicense from the City of Orono or any of its departments <br /> may require you to furnish certain private or cor�fidential i�ormatlon. <br /> You are notified that: <br /> 1. The ir�formation you furnish will be used to determine your qualification for the permit or license <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permlt or license. <br /> 3. The inforrnation may be shared with other locai, state or federa!agencies to the extent necessary <br /> to process the permft or license. <br /> 4. If your requested permit or license requires Councif action to approve, some information may <br /> beoome public. <br /> 5. You have certain rights unde�Minnesota State Statute 13.Q4(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �� <br /> � <br /> F�rs# Middle Last <br /> _��-�'� ��,Yo�'�,. �� <br /> Address <br /> JV �"l l ��V�W <br /> C�tY State Zip Phone <br /> ! understand my rights as , <br /> ignat <br /> RECEiVED <br /> A11G 1 7�2016 <br /> CUP Applicatlorr—January 201 B <br /> �8 � � � �� CITY OF ORONO <br />