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DATA PRIVACY ADVISORY <br /> In accordance with M.S . 15 . 165 , "Rights of subj�cts of data" , <br /> we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may <br /> require you to furnish certain private or confidential inform- � <br /> ation. <br /> You are notified that: <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested . <br /> 2 . You may refuse to supply data, but refusal may require <br /> that the City deny the permit or license . <br /> 3 . The information may be shared with other local , state <br /> or federal agencies to the extent necessary to process <br /> the permit or license. <br /> 4 . If your requested permit or license requires Council <br /> action to approve, some information may becom� public. <br /> 5 . You have certian rights under M.S . 15 . 165 to review <br /> private data on yourself . <br /> 6 . Your ful]. name, and date of birth are required to process <br /> this application or permit. <br /> . -�o(�N �-r U . 1{n�t-�n1� .1) <br /> First Middle Last <br /> .S3� �-F-r>,n)�Lc�:�+ f�v � _ <br /> Address <br /> t�a�� ��--,A ►'''� N - - - - <br /> 53 <br /> �� � - 3� � � <br /> P one <br /> I understand my rights as stated above. <br /> X --�r*,����'� �� �-�-`� �� <br /> Signature ` <br />