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DATA PRlVACY ADVISORY <br /> ln accordance wifh A+9innesata State Statute 13,04 Rights of Subjects of Data, Subd. 2, "Tennessen waming', we <br /> would like to inform you that your request for a permit or license from the City of Orona ar any of its departments <br /> may require you ta fumish certain private or confidentfal i�orrnation, <br /> You ere notfied that <br /> 1- 7he informaqon you furnish will be used to determine your qual�catfon for the permit or I�ense <br /> r+equested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the pe�rm�t or Ycense. <br /> 3• The infnrmation may be shared with ather local, state or federai agencies to the extent necessary <br /> to process the permif or I�ense. <br /> 4. If your reques#ed permit or Ifce»se requires Coundl action to approve, some (nformaHon may <br /> bec4me pubiic. <br /> 5, You have certain rights under Minnesota State Statute 13.04(see fdlowing page)to review private <br /> data orr yourself. <br /> s• Your fu8 name is required to proc8ss this application ar perrnit, <br /> First �� � <br /> Middie Last <br /> t C3 o t nd l.,a�n <br /> Address <br /> 55�,� �BS�-3a l q <br /> ��tY �e �p P�one <br /> 1 unders d my rights as stated above. <br /> `/� <br /> Signature <br /> ��C��V�.� <br /> Va�iance ApplFceNan--May 201 B S�P 2 � %��': i <br /> Peoe ia <br /> � � � 7 � �ITI(OF ORONO <br />