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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 /> PA ic221/ <br /> First Middle Las/ <br /> 1-`1 t o /C:\., <br /> Address <br /> ol) • it-4.) ,575-3 LA 3 (iia -30 -33o\ <br /> City State Zip Phone <br /> I under nd my rights as t 'd above. ,7 <br /> °/6/9/Y <br /> ure <br /> RECEIVED <br /> CUP Application-January 2017 Page 14 FEB n 7 <br /> 2017 <br /> 3 07 CITY OF ORONO <br />