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r � <br /> 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 /> First Middle Last <br /> z.�- . too _,. _4',• 1. � i'� • , <br /> Address <br /> �`` <br /> t <br /> City State Zip Phone <br /> I understand my rights as stated above. <br /> Si•/ <br /> -ture <br /> RNGEIVED <br /> DEC 12 2017 <br /> Subdivision Application-January 2017 # 3 9 96 CITY OF ORONO <br /> Page 13 <br />