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� r <br /> ; <br /> ;•�� ,'; <br /> ��� r� <br /> .�:' `'� :�� <br /> _ �� <br /> ! <br /> DATA PRIVACY ADVISORY <br /> �In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects of <br /> data , 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 require <br /> you to furnish certain private or confidential information. <br /> -you are notified that: <br /> ' l. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or <br /> permit. <br /> ��V C�� ��, ^�,���•' /����/�� n�, <br /> First <br /> Middle Last <br /> i��6� /�%�,� TQ.��� �� <br /> Address <br /> ° rr ��r /�1�-' -,� 3 `"/ `� <br /> �� �-� /'� <br /> City State ZzP <br /> 9�jz - � � ys <br /> Phone <br /> I understand my rights as stated above. <br /> �L 2-L� .��. ��-C�----�.�. <br /> ignature <br />