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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 refusaf 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 Iicense. <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 /> I �:e. � '�o.(�p r--4— 1 Y\J ��--C r\�.c� ..� <br /> First Middle Last ` <br /> _('S/O l `J`�11 F �: dai P �I 1`�C � <br /> Address <br /> _ W�t�l �� !/Y ► N 'Js3� l �P/�•�67• 59'SS <br /> City State Zip Phone <br /> I understand my rig s s ted above. <br /> \ �c <br /> Signa e <br /> Packet Last Updated: 04Ji9/2013 <br /> Page 20 of 23 <br />