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DATA PRIVACY ADVIS•RY <br /> In accordance with Minn-sota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we <br /> would like to inform you hat your request for a permit or license from the City of Orono or any of its departments <br /> may require you to furni h certain private or confidential information. <br /> You are notified hat: <br /> 1. The info mation you furnish will be used to determine your qualification for the permit or license <br /> request gid. <br /> 2. You ma refuse to supply data, but refusal may require that the City deny the permit or license. <br /> 3. The info mation 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 /> Xkomoka__ I <br /> First Middle Last <br /> /E--) 2,o0 -73' 4 <br /> Address <br /> /Ltd e fi(A) 60 -0163 <br /> City State Zip Phone <br /> I unders nd my Jig s as tated above. <br /> e.•••-L (Lie lanT7> <br /> Signature <br /> Packet Last Updated: April 2016 <br /> Page 9 <br />