HomeMy WebLinkAboutData Privacy Advisory FormDATA PRIVACY ADVISORY
In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we
would like to inform you that your request for a permit or license from the City of Orono or any of its departments
may require you to furnish certain private or confidential information.
You are notified that:
1. The information you furnish will be used to determine your qualification for the permit or license
requested.
2. You may refuse to supply data, but refusal may require that the City deny the permit or license.
3. The information may be shared with other local, state or federal agencies to the extent necessary
to process the permit or license.
4. If your requested permit or license requires Council action to approve, some information may
become public.
5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review private
data on yourself.
6. Your full name is required to process this application or permit.
Piro ¢L,I— +A"00;0al
First Middle Last
1,;Vo $2.&G� t%1h,1CN7- RDA..l>
Address
O 2 o n1 o M t l ri 53a r It 5'2 • Li-7 I A't
City State Zip Phone
Variance Application - January 2017
Page 14