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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 /> 1—,4(1, t il.4-6 r/vu.t.-l <br /> First) Middle L s <br /> Address o . n <br /> 0 r1Tr\--0 Iv110 I D\ ct Li <br /> City State Zip Phone <br /> I understand m ghts as stated above. 1 <br /> -4111 <br /> Signatu <br /> Vadences Applioation—Jartuaty2oi7 RECEIVED <br /> Page 14 <br /> AUG 2 3 2017 <br /> # 396 r Cmr OF ORONO <br />