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� � � f <br /> ♦ R' � <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 <br /> private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> � <br /> -�'.-� /f ��-� ��� ��,��, �-� <br /> First Middle Last <br /> � r <br /> � <br /> -��a� �r �i J-/ <br /> Address <br /> %'j'!°J _�� Z--7��—��.� C°e��C� <br /> Cit State Zip Phone <br /> understand m ts as stated above. <br /> �� <br /> e <br /> PacketLast Updated- January 2015 <br /> Page 7 <br />