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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Date,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 private <br /> data on yourself. ' <br /> 6. Your full name Is required to process this application or permit. <br /> ail 67 . W4C-CC7� <br /> First Middle Last <br /> 513Q f 1i J /- La,ne, <br /> Address <br /> p\j-Moi4-141 MAI ( 56-2/4Ze <br /> Ity State Zip Phone <br /> I understand o .hts as state• 'ove. • <br /> l <br /> Air <br /> Signature <br /> Packet Lest Updated: August 2015 <br /> Page 7 <br />