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DATA PRIVACY ADVISORY <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, 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 /> 41)A4 bc..11 <br /> First Middle Last <br /> Address <br /> :a1izi (i44) s5"- � z- <br /> City State Zip Phone <br /> t unde : i rights as stated above. <br /> Sig <br /> RECEIVED <br /> DEC 14 2416 <br /> Variance Application—May 2016 <br /> Page 10 CITY OF ORONO <br />