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, <br /> �� <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#o 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 /> > .. <br /> L✓� ���.�j�.Ydl 1,/v ��w e <br /> "v <br /> First Middle Last <br /> � io s� s-��i .s� # /�� <br /> Address � <br /> . %�� l� /�.�� �`5`�r U� . ���-�p�'-� t Z�� <br /> �� <br /> � City State Zip Phone <br /> I understa my r' ht s� ed abov . <br /> , <br /> ,= <br /> gnature /� <br /> �'�C�O�/�� • <br /> APR 19 2013 <br /> CITY Cl� �F�pNp <br /> Packet Last Updated.• 03✓29/13 � <br /> Page 14 of 29 <br />