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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 not�ed that: <br /> 1. The inforrnation you furnish wili be used to dete�rnine 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,/z��.�f <br /> First Middle Last <br /> � �/ .� �i�.,�� �� ��'� .�� /'�� <br /> Address <br /> �J���� <br /> City State Zip Phone <br /> I understand my rights s stat e. <br /> Signature <br /> Packet Last Updated.• 04/19/2013 <br /> Page 20 of 23 <br />