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DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would like to inform you that your <br />request for a permit or license from the City of Orono or any of its departments may require you to fiamish <br />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 to <br />process the permit or license. <br />4. If your requested permit or license requires Council action to approve, some information may become <br />public. <br />5. You have certain rights under M.S. 13.04 to review private data on yourself <br />6. Your fiil1 name is required to process this application or permit. <br />7. Per Chapter 30 of the Orono Minnesota City Code, a computerized criminal history inquiry and/or mm <br />driver's license history inquiry on the applicant may be conducted to verify the information provided <br />with the application. <br />NAME: <br />middle last <br />ADDRESS: kLZS =a -- <br />house number street <br />city state zip <br />DATE OR BIRTH: _ -1 PHONE: to ptlgA <br />me th/ diy i year —_ <br />I understand my rights as stated above. <br />signature <br />page a <br />