Laserfiche WebLink
Exhibit 3 continued <br /> CONSENT TO RELEASE PRIVATE DATA <br /> I, authorize the City of Arden Hills ("City") to <br /> (print name) <br /> release the following private data about me: <br /> to the following person or people: <br /> The person or people receiving the private data may use it only for the following purpose or <br /> purposes: <br /> This authorization is dated and expires on <br /> The expiration cannot exceed one year from the date of the authorization,except in the case of authorizations given in connection with <br /> applications for life insurance or noncancelable or guaranteed renewable health insurance and identified as such, two years after the <br /> date of the policy. <br /> I agree to give up and waive all claims that I might have against the City, its agents and <br /> employees for releasing data pursuant to this request. <br /> Dated: <br /> Signature <br /> IDENTITY VERIFIED BY: <br /> Witness: <br /> Identification: Driver's License, State ID, Passport, other: <br /> Comparison with signature on file <br /> Other: <br /> Responsible Authority/Designee: <br /> 190435v1 <br /> 14 <br />