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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen <br /> waming", we would like to inform you that your request for a permit or license from the City of Orono or <br /> any of its departments may require you to fumish ce�tain private or confidential information. <br /> You are notified that - <br /> 1. The information you furnish will be used to determine your qual'fication 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 Minnesota State Statute 13.04 (see following page) to <br /> review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> `T�ta Ma.S �1+L1��om r"o I ll°lr <br /> First Middte tast <br /> 1053� �evon.sh�re. �r�ve. <br /> Address <br /> �nl�asser� �Y1 f� �5�l'� � I a-�8a-"1�--� � <br /> City State Zip Phone <br /> I unders nd my rights as stated above. <br /> � <br /> Signature <br /> Packet Last Updated.� 04/19/2013 <br /> Page 20 of 23 <br />