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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 /> warning",we would like to inform you that your request for a permit or license from the City of Orono or any <br /> of its departments 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 <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 review <br /> private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> �� l Lin e. -S t-- \\ ,--. 2 LA <br /> First ' ',5 Middle 1 Last <br /> Address e <br /> —'--1.— `f \ v�?/IC .3 y L'1 — 1 S2 - 71,--/- ole") <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Signature, �J (/ <br /> 4 <br /> ( <br /> Subdivision Application—January 2017 <br /> Page 13 <br />