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# � <br /> T� OF ORONO � 6124730510 09/24/96 14:00 �1 :03/03 N0:�22 <br /> �ec>13,04 itIG1iTS OF SUHJ�CTS OF DAT� <br /> Subd. 1. Type o(ds4. 1Re dybts of indlvidw!on�vhom the data 1�c�ored or w be stored�hall bs ax set forth In thlt�eadon. <br /> Subd.3. Iedonnatl.�reqtdr�d to M�indt•idnpl. An Indlvidual asked ro�upply priwa or oonRdentid d�a wnasrning hic�uelf Rhs11 <br /> be fnfo�med of: (a)tha purpoce utd inaaded u�a ot Du tequescod d�a widdn rhe wtlecdn�liate�genoy.polldpl aubdlvi�an,or natnu+ide sywsm: <br /> (b)rrfiether M n�y mflite oT b k�lly mquired w supply the tsqueual dua:(c)ary known eonsequen�e tri�ing from hts tupply ln�or relluln�ro supply <br /> privue oe conMeddai d�a;and(d)�he idendty o!od�e�person�or encloes author�ed by sum or fateral!xw m rcceive the dau. Tht�m�ulrcmeac shull <br /> aoe apPly,vheo an l�tiridu�l b Asked�o mpply lnvestiaadve daat.punuani�o cscdnn 13.82,subdivision S.to a I�w enfo�cmem o�er. <br /> ,.+ <br /> 7t►a cnm�i�,�{gnc�J�y�Q�e ma� ulice no�ce re itsd undtr this subdf�ifion t�t,�e ind�vidua!_income csx or orocem nz�;nl�ir�, <br /> _ " jp�tcucdoai in�u�l uj on�o o tor��, . ' � <br /> �uEd. 3. Acew eo data by indl�idwl. Upon rcqueu to a recpamible w�ho�iry.�n ladi�idud shall be lnforrtud whather 6e b t6e wbject <br /> o[rwred dKta on iadlviduali.and wh�dter ic is ciass[fied a�public.P�iva�e or caJfdepdtl. Upon hi�Aud►er request.�n individual wlw i�rhe subjdct <br /> of aored pri�rce or publk dw nn individuals shill be ahow��he dan widiouc aay ehar�e w him u�d;if he dedces,th•fl be infoedied of t6e conoenc <br /> �nd�ahnieis of tfi�t daa. A(ur an itxlividuat lw beeo shown thm prl�ate dtu u�d fufo�med of[u uteanws.the thu cmed aorb�di�elosed W dim far <br /> d:eeoadis tkersafter uNeu a dispute or accion punuanc m �hi�seedoa is pendlaQ or addidoml dua on t6e indhridu�l hat been oollected or creued. <br /> TUe t�ywtuible tuthpriq e6all provide copiet�f rhe privam or publk d.a upoo riequeu by�6e individual wbJer.�of d�e dua. TM nupoa:ible suthoriry <br /> puy require dre mqus�tin�person ro pay d�e aaarl cosa of makina.cercHyinr.ud nompflia;d�e eop��. <br /> The Ksponeible wthoriry.�11 comply imnasdiately, if pogtbk.Mith ury roquest mede puceuant oo tbls rubdivision,or.vii6lq flye day�of <br /> d�e date of the roquee�.exctudinQ 9awtdays.SunQays�nd la;d holld3y�,ff i�mnedlace comptlance is not po�siWo. 1Nu caruwe comply whh d�e requesc, , <br /> �rltbin duc dme.he sb+dl w iNbrm dw iadividual,and rtuy hR�e an.ddleiop�l five d�ys wld�ln whkh co coroply wtdi die cequeat,excludlog Sawrd,ys. <br /> �yi�ed let�l holld�y�. <br /> Subd.�. Ptotedur�whi�ti dala Is net aeeurat�or complKe. An indlvidua)m�y coaoeu the ucu[aey er compluenoa�of publk or privue <br /> d�a eoacornln�bi�elf. To axercise�f►is dght,an indiVidue!shall uoeily ia�+cidno�+e reeponsibk sudu,rlq�dem{blo�d�ntauro of rho dl�yreemenc. . <br /> TLe te�poarlble�uthoriry�hdl within 30 days eirher, (�)comec the data found w ba inuwcue or incnmpteu�nd�aempt m aoafy p�a rocipkna of <br /> (cueweate o�fncwmplete d�n,Includin`rocipknw named by�e indiridual:or(b)notify the individtul th�t he belleves q�a dus ro b�eotraee. D�a <br /> la dkpuu ihsll be d'uclo�ad oNy if tha indlvidusl's satemaet of dlt�{ramenr b includad widt�he discloud d�m. - <br /> 3'he determination of�he rrsponsibte au�horiry may bo appeakd putYuaoi ro th�provkbn�o(ihe admtnicaadve procedure ux relwcin�w <br /> conoe�ed cafes. <br /> � � DAT�$�YYAC�El��.QRY • <br /> !n atcorduvice with M.S. 13.04,Subd.2� "Itigh�s af suFiJects of da[�', we woutd 19ke to infocm you that yo�r requesc <br /> for e pe�rmit or ltcense from che City of Orono or any of its departt�euts uu}y requlra you to furntsh cer[ain private or <br /> confidenNal information. <br /> You are aatified that: " <br /> 1. The information you Pumish wil!be uscd to decermine your qualificuion for ehe permic or iicense requa�ced. <br /> 2. You may refuse to supply daza, bur rcfusal may requlre thac the City deny the permlt or licettse. <br /> 3. The information may be ahared with othcr local� state or fedetal ageaciaa to the extent nccessary to process <br /> the permic or license. <br /> � 4. . Yf your requaeted permit or license requirec Couucil �etioa �o App�ove, some infarniatlun may become <br /> ' publk. <br /> S. You have eercain righcs under M,S. 13,04 (avoilable upan tequest) to review privata data on yourself. <br /> 6. Yaur fult cu�me is requirtd to process_thls applicuiou or pccmic. <br /> . O�`o.KCj. `nQ�� �`�C�(L� � <br /> , � Ftrn • Mbddle I.asc <br /> ��a� �. $o+�, ��. s-�.#a�� _ <br /> ,�, . . � mtv � y � `�S 45•(00�1�� <br /> �� _. .__ . ada z�p rbo� <br /> ; <br /> I•understand my dghts as scaced nbo�+e. <br /> :.�%�Y`.�,,���, <br /> 8ignuture <br />