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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 (icense 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. `"i � <br /> 6. Your full name is required to process this application or permit. <br /> . �G�(i9'.(� t • L��C°rr G/L `.�Cit/ ( / <br /> �First Middle Last <br /> �'�'DS' {�'�-�-{��� �.- <br /> Address <br /> (,�c�y2m�� . . �� ��'3�� ��sz� �7S /7�? <br /> City ' State Zip Phone <br /> I understand my rights as stated above. <br /> �i/%2� .. <br /> —, <br /> �� <br /> Signature <br /> ,.���.. <br /> RECEIVED <br /> VarianceApplication Updated: January 31,2012 <br /> JUN 2 0 2012 <br /> - 15- <br /> " ClTY OF ORONO <br />