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. .. <br /> �,•. .r� f 'F'' . ,t� <br /> *�4 � � I^' �� <br /> ��'i• A ' ;' - . . <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data" , <br /> we would like to inform you that your request for a permit or <br /> license from the City of Orono or any of its departments may <br /> require you to furnish certain private or confidential inform- <br /> ation. <br /> You are notified that: <br /> 1 . The information you furnish will be used to determine <br /> your qualification for the permit or license requested. <br /> 2. You may r.efuse to supply data, but refusal may require <br /> that the City deny the permit or license. <br /> 3 . The information may be shared with other local , state <br /> or• federal agencies to the extent necessary to process <br /> the permit or license. <br /> 4 . If yaur requested permit or license reqires council <br /> action to approve, some information may becom� public. <br /> S. You have certian rights under M.S . 15. 165 to review <br /> ' private data on yourself. <br /> 6 . Your full name, and date of birth are required to process <br /> � this applicution or permit. <br /> . �D�lerT F.� ���UAI'L <br /> First Middle Last <br /> SSaS IQ�JEQ ��u FF C��Q, <br /> Address � <br /> � Loom► NtiTo�/ Mi✓� ��SY3°7 - <br /> -T . <br /> Da�o�lirth (does not apply to building/general permits) � <br /> . .. _ _ <br /> l�omE 8��'39/� WcRff y.�3-4f�$v - : <br /> Phone <br /> I understand my rigfits as stated above. . _ . - ___ _ <br /> , . _ . = ._ _ -- ; :- __ - _ -- _ __-. <br /> X � :. . . - . _ <br /> . _ _ . _ _ - --. <br /> _ _ Signature ___�.. -- --- ---.-. __ . , _ _ _. . . . -.- = -. - ---_ <br /> —_, _�.-_-� :;.....��..:__ - _ - <br /> =- �--�,= - --:�_ : - _ . _ <br /> - -- - - - � - <br /> __... <br /> _. <br /> . - - - _ . . _ . --� ---- --- - --- � - - -- --- <br /> . . - � <br /> _ .. __, _ . -- -'- _ ..____ _. . .__ :.: _. �. _ _ - - <br /> . . _ ___ _. .. _ _--- __ _ . <br /> ,�:�_ <br /> . � _: <br /> _._ -_ �:_. -- -.. _ _ _ <br /> � . _ -_:, _ � ��- �- -� - - _ _ - - _ <br />