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DATA PRIVACY ADVISORY <br /> in accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen waming", we <br /> would tike 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 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 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 private <br /> data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> � <br /> irst Middle Last <br /> 2�<ID�S NN��� ��,�� <br /> Address <br /> �L I � <br /> City State Zip Phone <br /> I un rstan rights as stated above. <br /> ignature <br /> Padcet Last Updated: Apri12016 <br /> Page 9 <br />