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�09/25./2698 13:64 9529601843 ALLPROXTERIORS INC PAGE 03/03 Sec.�3.04 �GHT3 O�'S(J�TBGT3 O,F AA,TA Subd•l. Type of date. The rights of individual pn whom the data is stoced or 6o be stored sha11 be a4 set forth m this section. Subd.2. inforn�ation reqwred to be given individual.At�individual asked to suAP�!Pm'�a confidential daraconceming hur+selfshall be imEa+ned of: (a)the purpose and ia�tended use of tbe�eque�ed data wichin ehe collecting sta6�agency,political subd�ivlsion,or ata�wide systom;(b) whetlle�he may refuse or is legal ly requiied W supplY ttw tequesbed data;(c)any latpvm apnse�uence az;sing from his supplying or re£ysing cv aupply privaoe o�con5dencisl dsm;and(d)the idenciry of odur persor�s or entities aurkwriud by atace or�oderal law w r�ceive the deta This requiremern ef►eU K►ot apply when an individual is aSked to supply ipves�igative data,nursuant to secdon I3.82,�subdivision 5,m a law enfore¢merat o$'icer. The icainner of neveaue mav elace th�n�siee reo�d�mder this+ybdivi�` in die'r+divi ,�i+�n,�,e ta�c or instrs.r`tions in.atead of on th�s��g d►.., Jmaoenv�refund Subd,3.Acass to dsra by individual.Upon request co a responsible auttwdry,an ihdividue�sha11 be infnnned wheit�er he;s tfro y,�bjecc crf slored dura on individuals,�d whether it is classified as public.private or confidendaJ, Upon;his fwrd�er reques�an individual who is�he subject of stoied private or public data on indivi,duals shall be shown the da�without arqr charge to him snd,if he desires,st,a11 be u,fwtned of the co�Renc snd mesnin�of that dara. A;Ret am irdividual has been shown che}uivate dsrs and informed of i�meaning,the dsta peed not be diselosed to him for eix mollths thueaRe�W'dess a dispuoe oc eetion pursuam tp chls seetion ia pending pr additirnml daia op 4he individual hss been eolleetcd oe c�oa6�d. The responsible auehoriry shall pmvide aopies of the privsse or public dara upon request by s�e individual sut�ject of d,e da�. The rwsponsible aurho�iry �Y�9uire the re9��B Peca�n to pay the actual costs otF inak+n�„cartifying,�nd compiling fhc copies. The responsible authority yhsll comply immedi�ely,if possible,witit any roquesc I�Iede pursuant W tbis subdivision,oI'wiLhin£tve days of tHe daze of the requesS e�xluding Sacundays,5usidayro and logal bolidays,if immcdiatc wmplismce is�o�possibla(the c�tot cpnplY wjth the t within that time he ahall so inform tha individual end � may have an addirional fivedays widainwhichto complywithU�erequesSexcluding SahudaYs, Sundays and logal holidays. � Subd.4. Procedure wha�dats�is not acGasEe or compl�e.An individusl may contwt the accucacy oc coanpletpiess ofpublic or private deia conoeming himself. To exucise this rtgf�t,an'indididual stwll nod�V in w�iting tlu respoasible auttwrity describiugtlu nehae ofdu disag�asnc'17�e res,pocroble authority shall wit�in 30 days eicher: (�corroct r.he data Eoiatd to be iin,tacurate or incomplete and atfempc w ratify past xeeipients of inaccura6e oi i�eomplete data,ineludine eecipienta named by the individual;o�(b)notify she indi�nidua)tlwt hc believaslhe daca oo be eorrcct.Dam in • dispute shall be disclosed only if the individuel's s�ate�nwt of disagreement'is included with thb disclosed data : The decumination of the reaponsible authoriry mar bo aippealed pureu�rct eo the pniviaions o£the adminieaupve procedtue acc relating to corrcested tases. DATA�1t�VACY ADVIS�RY ln aceordance wit�M.5.13.04,Subd.2,'Rig6�ts of subjects of data",we wowld Iflke to iafoma you that your request foc a�it or license from�the City of Oro�nv or any of its deparhnents may require you to furqish eertain pnivate vr confidential ua�ormation. • You are not��ied that: � 1. �'1�e infurmacaon you furnish will be used ro decemnine yo;wr qualificat�on for the pexmit or lie�se requosted. ; 2. You may re;[use to supply data,but refusa��may.requirc that the City demy t�e perinit ox lacense. 3. 'x'�e informatio�t�7nay be sbared with other local, 5tate or fedexal agencies to the extcnt necessary to proCess the pe►imit or licepse. : 4. If your xequested pamit or license requires Couneil ac�hion to approve,Some�fqrimatio�may beeo�oc�e public. , 5. Xvu k►ave certain rigk►ts under M.S.I3.Oa(available upon reguest)to z�eview private data on yourself 6. Xour ftill name as required to prucess this app�cation or p�rnpi�t. �� ►�,�C r ors � v�L. : _ .— F'ust Middle . �,� 1�3s �a�4- ad! �� 5� � _ Addras � � v��r-��v�+ 1��1 553�3 9_5� �I'8�to-�83y� City 9tsih ' Zip �bone i unde�rstand my rigbrs 9s sts�ted�bove. . 3igwmre I _ 32 ;