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DATA PRNACY ADVfSORY � <br /> In aocordance with Minnesota State Statute 13.04 R�ghts of Subjects of Data, Subd. 2, 'Tennessen waming", we <br /> would like bo inform you that your request far a permit or license from the City of Orono or any of its c{epartments <br /> may require you to fumish certain prnrate or oor�fidential information. , <br /> You are notfied that <br /> 1. The iniom�ation you furnish will be used to determi�e yaur qualfication for the pertnit or license <br /> requesbed, <br /> 2. You may reiuse to supply data, but�efusal may require that the City deny the permit or liCense. <br /> 3. The information may be shaned with other local, st�ate or federal agencies to the extent necessary <br /> to process the psrmit or license. <br /> 4. If your reqUested permit or license requires Counal action to approve, sorr�e ir�foRna�on may <br /> beCome public. <br /> 5. You have certain rights under Minnesota Stat�Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Yoar full name is reQuired to process this applicadon or perm{� <br /> AX1 ��' �j��-t1��� <br /> 1�► C�6�t3b�v g <br /> First Middl� Last <br /> �� �`�h 1`�"� ..�VE'� <br /> Addre55 '� "' <br /> i <br /> r W 1�.-�i1v7-(QG`� <br /> —��� �1 N �?a�I �fz- ��� -v � <br /> City State Zip Phone <br /> I understand my rights as stabed above. <br /> �� .�� <br /> si ture . , <br /> �����{� <br /> SEP 21 2�16 <br /> Varfance Appricefbn—May 2016 <br /> Page 10 � � � *� � C�Y OF QR�l�ld <br /> � <br />