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SC, Z- <br /> 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 /> 67\ Your full name is required to process this application or permit. <br /> L-0[AIE <br /> First Middle Last <br /> 9-11)5 (\iPu P-diao4 <br /> A..ress <br /> O <br /> City State Zip Phone <br /> I un and my rights as stag: •ve. <br /> ature <br /> RECEIVED <br /> CUP Application-January 2017 Page 14 3 3 <br /> MAR 2 9 2017 <br /> 3 <br /> g CITY OF <br /> ORONO <br />