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DATA PRNACY ADVISORY <br />In accordance with M>Tnnesoal State Stshft 13.04 Rghts of Subjects of Date. Surd. 2, 'Tenn ae m <br />wamW, we world tike to knform you that yoour request fora permit or license hon the City of Orono or any <br />of its departments may require you to furnish certain private or confidential kibmation. <br />You are notified Mal: <br />1. The kdDnradion you furnish vO be used to determine your qualification for the permit or <br />BOW" requested. <br />2 You may refuse to supply date. but refusal may require flint Me City deny Use pemd or <br />Brans. <br />3. <br />The inkanation maybe al -wed with oMer local state or federal agencies to the sa dW <br />necessary to process the permd or Hoene. <br />4. If Your requested penmd or Doane niquires CoundF action to approve, some inknnstion <br />may became pubilm <br />S. You have cartain rights under Minnesota State Statute 13.04 (see fbkm* g page) to review <br />private date as yourself. <br />B. Your AA name Is required to pnxxes this application or permit. <br />./ * 0,5 v <br />FM I tiMddte 11"d <br />J <br />sum <br />I understand my rids as stated above. <br />Payr 13 <br />(1V41e.— <br />