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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 /> 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 th�application or permit. <br /> � ��,�� `TY <br /> � �, <br /> First iddle Last <br /> �Ll� �n �Q G���� _ <br /> Address <br /> o�o� �. . ���� q.�a-y73 -���� <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> " ` d7/- �,��-�—'. . <br /> Signature <br /> � � RLCEIVED <br /> Packef Last Updated: 03/29/13 1 ` APR 17 �013 <br /> Page 14 0,. �S�O� ORONO <br />