|
.
<br /> . . , — O�l
<br /> -, �
<br /> � ' r
<br /> O O
<br /> - = CITY of ORONO
<br /> ,�. -: r �.,- : �., `z���►o� .
<br /> ' � ��` ti P�o�soX�
<br /> �� •�-�''� '-;- '� ('j~' Cn�stal Bay,.'�I'innesota 553��0066
<br /> � ��� � '�
<br /> .`q.FfES�-1�4
<br /> ;�..
<br /> DATA PRIVACY ADVISORY
<br /> In accordance �c-ith �Z.S. 13.04, Subd. 2, "Rights of subjects or data", we would lil:e to
<br /> inform you that your request for a permit or license from the Ciry of Orono or any of its
<br /> 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
<br /> permit or license requested.
<br /> 2. You may refuse to supply data, but refusal may require that the City deny the
<br /> perrnit or l�cense..
<br /> 3. The information may be shared with other local, state or federal a?encies to the
<br /> exter,t necessary t� p:ocess th� permit or license.
<br /> 4. If your requested permit or license requires Council action to approve, some
<br /> inf'ormation may become puoiic. . .
<br /> 5. You have certain ri�hts u�der M.S. 13.04 (see followin' paQe) to review private
<br /> , _ data on yourself: , , - �_
<br /> , . -, . .. ,.. �
<br /> ,._
<br /> . 6. ,Your full name is required to process this application or permit. ; � , � •
<br /> . . ._ _ . , � . . _ . . . _ `� . . ' .
<br /> , .. ,. ,. . _
<br /> .:.: ;,.: : ..
<br /> PLEASE PRL�'T`, '.... : _ , . . .� �c :.
<br /> � � � . . . . . _.���_ F_ '.� �� . � . ,_.... � :. �, . ., . _ . .. . • � ��. . .F�. .. ,� .. . . .. . .,J...
<br /> �
<br /> .: . First = - __; ;; Midd:e�: -, ; , � . LaSt .. � :
<br /> .. . . .. � . . .. .. .. �f'� .. . ... ���', . _ -._ ._ ' . . .
<br /> T . '���O �.� ' V .� � `� v`�_ - ` ` '..� ' __
<br /> -�. :. . , . . .. . . . _ . . . .
<br /> . Address ._ , ,
<br /> : ; mN _ ss3� � - 03
<br /> •Ciry . _ _ State � ., : Zip Phone
<br /> A
<br /> ... . ...,.. . ... .. _ .
<br /> � I understand m ri�hts as stated above:�-
<br /> � a_ �.. < i:'�':�.� ti s _ . ; • . .. . . ' . , . ,
<br /> �
<br /> SiQ ture -
<br /> � TEI.EPH01YE-473-7357•F.4X-473-0510
<br /> • 10
<br /> _ . __ __ ___ � __ �._ . _ ._ _ __ - - - - -
<br /> .� __ __
<br /> _. _ _.. . , . ,:.. ... . ,�. _ _ _ -
<br /> ._ .. �__
<br /> _ ,., . . . w.. .. .. .. ,.�,�;�..- ,,,.�,-, .�.;T-� �w;
<br /> ____- �..__ „.,,
<br /> . Y------ _.:.__.__.�_ _,--------- -----
<br /> _._ _--- __-- ---- ---_--- --
<br /> --�.,..--,....-.�.�,��,,.,..
<br />
|