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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.�4 Rights of Subjects of Data, Subd.2, "Tennessen warning", we <br /> wo�ld like to inform you that your request for a permit or license from the City of Orono or any of its departments <br /> may require you to furnish certain private or confidential information. � <br /> You are notlfied that: <br /> 9. The information 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 permit or license. <br /> 3. The informa6on may be shared with other local, state or federal agencies io the extent necessary <br /> to process the permit or license. <br /> 4. lf your requested permit or license requires Council actlon to approve, some information may <br /> become public. <br /> 5. You have certain rights undet Minnesota State Statute 13.04{see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit, <br /> �'QS <br /> First Middle Last <br /> 5� a� ,5�a�¢ �G, <br /> Address <br /> �obb�S���G c�N 5 s���- , � , S <br /> �v5 2 t� a� � <br /> C�Y . State Zip Phone <br /> I understand my rights as stated above. <br /> • � , <br /> i re <br /> RECEIV�D <br /> SEP 21 2016 <br /> v8►►ance Appficanw,—Mey zo�s <br /> Psge 1� � � � � � ,v`` f ���N� <br />