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DATA PRIVACY ADVISORY <br />In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessee <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 I'icense. <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 />First Middle Last <br />Address <br />�( C' ff-5 <br />city <br />I <br />State <br />I understand my rights as stated above. <br />;5- <br />Zip <br />Phone <br />° a-�27- ?c 'i <br />RECEIVED <br />DEC i 3 2017 <br />Subdivision AppWatfon — January 2017 <br />pa' 13 CITY OF ORONO <br />