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� o <br /> � � <br /> o , o <br /> ��— CITY of ORONO <br /> � �������'� �`��'�'� � Municipal 0ffices <br /> �� �� �;��* � ti Past O�ce Box 66 <br /> "��'':3,;r�'t«,��G cry��y,M�n�ss3z3-oo� <br /> L`4kEsHp4� <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "RiQhts of subjects of data", we would lil:e to <br /> inform you that your request for a permit or license from the City of Orono or any of its <br /> departments may require you to furnish certain private or conf'idential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the <br /> permit or license requested. <br /> �. You may refuse to supply data, but refusal may require that the City deny the permit <br /> or license. <br /> 3. The information may be shared with other local, state or federal aaencies to the extent <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some <br /> information may become public. <br /> �. You have certain riahts under M.S. 13.04 (see followin� page) to review private data <br /> on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �M(`1'7�1�'�- ���S�'� !�f�`� <br /> First Middle Last <br /> l GI�i�v �s����� <�v�� " - <br /> Address � <br /> `�,��'�'� �'x� /l�� .5�33/ � ,��lex�v <br /> � �, � <br /> City , State Zip Phone <br /> I understand my rights as stated above. <br /> ``�� � ; <br /> ,� /,�^�� V ' �n..,�_. <br /> Signature <br /> TELEPHONE—4r�7357� FAX-473-0510 <br />