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DATA PRIVACY ADVlSORY <br /> In accordance with Minnesota State Statute 13.04 Rights af Subjects of Data, Subd. 2, "Tennessen warning", we <br /> wo�.�ld like to inform yau that your request for a permit Qr license from the Gity af Oron� or any of its departments <br /> may require you to fumish certain private or confidential information <br /> You are notified that: <br /> 1 The information you fumish will be used to determine �our quali#ic�tian for-tne perE��it or license <br /> req uested. <br /> 2. You may refuse to supply data, but refusal may require that the City deny the perrnit or license. <br /> 3. The inf�rmation may be shared wifh other local, state or facieral agencies to the extent necessary <br /> to process the permit or license. <br /> 4. tf your requ2sted permit or license requires Council acti4n to approve, some informat;on may <br /> become put�lic. <br /> 5. Yau have�certain rights under Minnes�ta State Stafute 13.04(see foi�wing{�age)t�revFe�,vv private <br /> data on yourself. <br /> 6. Yaur(u{I narne is required to process this application or permit. <br /> � - �o�+.� I.�,t� �A�Z_ . ` <br /> � � <br /> First Nliddle Last <br /> t�. o . ���� � <br /> Address <br /> c�. S-,� �� M� s s3a-3 �l�-- � ys-y �� � <br /> City State Zip Phone <br /> ! understand mg+ri��its as statec#�af�sve` <br /> . � � <br /> �� <br /> Signature � <br /> i <br /> � <br /> x <br /> 5 <br /> Packet�ast Updated: Augrrs�2u'15 <br /> Paqe 7 <br /> s <br /> d <br /> a <br /> . .. _ .__. ...... . ...... . ... .. _.. <br />