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_—�_ , <br /> , • � �� <br /> � <br /> � � � of ���I�O <br /> - _ �I'�� <br /> it��o�� <br /> +� �`. � r��' - �''' <br /> P�a�soX c� <br /> ��' ��' '' .� 'ti Crystal i3ay,�f:nn�ota=�2�-O�Xib <br /> ��� �.`� � <br /> ,� <br /> ��9� -- .�� <br /> '�ES�I�;: <br /> ;- —�:- <br /> DATA PRIVACY ADVISORY <br /> In accordance «�ili`� �1.S. 13.0�, Subd. 2, "RiQhts of subjects or data", «�e would lil:e to <br /> inforn ��ou that your request for a p�rmit or license from the City ot Orono or any of its <br /> departmen�s may reauire you to furnisn cenain private or confidential inrormation. <br /> You are notiiied that: <br /> 1. Tne intorrnation ��ou furnish will be used to determine your quaiiiication for tn� <br /> permit or lic�:ise requested. <br /> �. You ma�� ren�se to supply daca, but refusal may require that the Ciry deny the <br /> p;;.�nit or �ic�nse. <br /> ; Tne information may be shared with other local, state or f�deral aRencies to the <br /> extent necessar`� to pr��ess the permit or license. <br /> � ?; vour requested pe.�nit or license requires Council action to approve. some <br /> inforr.7ation may becom� puolic. <br /> � �'ou ha�'e c�:"ajn r;�hts unde:' �1.S. 1�.04 (se� fol]owinQ paQ�) to review private <br /> data on �ou:sel�. <br /> 6, �'ou: `�ail r.a^,ie is required to process tnis application or pernit. <br /> PLE_�SE PRL\''I' �— <br /> �LoN 2� l3�rzo�l 5�r�-,.� C�� <br /> First �Lidd:e Last <br /> L�O�j�'J f�l(oft '-.lo00 �� <br /> .�C1Cress �7 j„_ 'Z,� "7 c� �� <br /> rt,�,.�/ 5� 3� ` _ _ 2 � -.' <br /> /v10�/�✓D Z:D Phone <br /> C irv S tate <br /> I underst:nd my riahts as srated above. <br /> Si�natur� <br /> v T-.L.EPHO\�-473-�57 • F.�k-473-0510 <br /> 10 <br />