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DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you <br /> that your request for a permit or license from the City of Orono or any of its departments may <br /> require you to furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish will be used to determine your qualification for the permit or <br /> license requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or <br /> license. <br /> 3. The information may be shared with other local, state or federal agencies 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 information <br /> may become public. <br /> 5. You have certain rights under M.S. 13.04 (see following page) to review private data on <br /> yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �,�� f� -1'}�-, �'��z I^�rJ <br /> Fir`st / , ( � Middle Last <br /> /',�/ "�� L�l l�)u'�1��'\ � Ci 1'�(\�� <br /> Address <br /> r�,,������ ��.� 5����1 ���.� - �� % t�- -�s a�f <br /> City State Zip Phone <br /> �-----_, <br /> ��y.� � �� ,�, _ ���--c��,� <br /> I understand my rights as stated above.'�..�_ <br /> �-._---�--------___--- <br /> � _._.__--- <br /> '`� "'�_...--- � --- <br /> --------_---_ . <br /> �` - <br /> Signature �� <br /> _ � <br />