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. <br /> DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br /> would like to inform you that your request for a permit or license from the City of Orono or any of its departments <br /> may 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 license <br /> requested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent necessary <br /> to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information may <br /> become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04(see following page)to review private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> ��Sr�r �'�- ,�?��t i �R 1�,�'r-fi. <br /> First Middle Last <br /> ���R l� ��'v;���'�. !i`��/'�r��'. <br /> J �1 <br /> Address <br /> �:r%r� ����,� til r � � J� "� '���� 1 <br /> / //�/�y/ / / .j <br /> � ��. ��. �Jj ✓I� `J� l_�...�� / �l �I�� l <br /> City' State Zip Phone , <br /> I understand my rights as state�bove. - <br /> ` � <br /> 1 � <br /> ���� ,/� � _����,�� � i <br /> ri <br /> Signature <br /> Packet Last Updated.� August 2015 <br /> Page 7 <br />