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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 certain private or confidential information. <br /> You are notified that: <br /> 1. The information you fumish will be used to determine your qualification 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 /> ��c.l��� �a3Efz� �oc�ES <br /> First Middle Last <br /> 3��'� c�c��� SE�� ���vE <br /> Address <br /> w�� 2�TA vtio� Ss�3�t I C��a —� �8 �- d��l�{ <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> � <br /> Signature <br /> Packet Last Updated: 03-06-2012 <br /> -19- <br />