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<br />. <br /> <br />. <br /> <br />{. <br /> <br />~ <br />~. <br /> <br />CITY OF AlIDEN IDLLS <br /> <br />GENERAL AlITBORlZA nON MID RELEASE <br />PURSUANT TO MINrlESOTA S'UTlJTJtS 13.os, SUBD. 4, <br />MINNESOTA DATA. I'RACTICES A.CT <br /> <br />To: City of Alden Hills-Amon,",n Schawn Johnson <br /> <br />di. K-J. ' <br />I .J1Jl ~ ._. ,,-It.J) M..J ' he1:eby al1l\1orizC and gl3l1t my mfanned com;ent Ul pewit <br />you Ul ,.\case'" IIld Ill" available to !he City of Jlroen Hills. MiDnoSOta, a>>dIor Us agents aDd/or repr:escntatiVCS <br />d3ta olBs5ifjed as private wbiob GOllce",S me and which may be in your pos.s...iolL The data whicb I authori.. to be <br />",,,,-,, conslots of pinlE i1alB as ddiSled by Mim1oso" Statue 13.02, Subd. 12, and bas been <:oJletl<d by you IS a <br />teSUlt of my cODlaClS and ..&ociatio.. wjth you and/or yaw: repr:escntative.. The infoxmation for wllicluelease " <br />aulllori2ed il1<;ludcs all dala. which bas beell <:ollect<d, "",at<d, m:civcd, retained, or <lis!eminatcd in whalever form <br />wlrich in any way tel..... to my deolings with you OT your agency. III.ndmtand that !be purpose of pcmIilting !he <br />City of Alden Hills 10 have access to 110. infonnation I. to clctertDine suitability for a charitable gambling ope_n <br />wjlbin the City. I filrlhe< und.-nd that th" info""",_ may subsOCp1ODllY be utilizod fo, other purpo... rel.liIIg <br />II> dlaritable gambling operations within the City. <br /> <br />By siSninIl "'is .u_tioD. (\Ie1:eby ...\e..., the Buuau of Criminal ~;.on frotn any and al\ liability whicll <br />olllerwi>e may or OOCS accrue as a to&Olt of the rel.... of any IIld all dala, rego>:d1css of i.. accuracy. (also ,.1.",", <br />tbe City of A.,detl Hills ftum any and alllio..1ity for its receipt and use of data received pur>nant '0 lbi& _I. <br /> <br />nus .uthomation.hall be valid for a period. of one yea" bull "",ervethe rigbtto, at any lime prior 10 thaI <br />ClCpiration. C8Ilc:d the writteJI au_tion by providing writt<n notice to the City of Arden Hill. Of to you of that <br />~facl. ,. l I . <br /> <br />~"'u_ ~.I0;J.L\u./ ;f...- i - b:-:- <br />19naNre ...... Date <br /> <br />G-o \ &\e..- K,rl\.. ~ r~l'\"'_ 5: <" :\ 0 ui /) (., -{; q - 3<f- <br />Full NamE _ Printed Date of Birth <br /> <br />SubsctibedandswomlObebelore~ J day of 0H{artf ,2002:. <br /> <br />_ \o..d:.f' J 1\ - 6viF-- ,NotBJ)'Public <br /> <br />PleASe "turn tet: <br /> <br />Scbawn Johnson, Assistant to the City AdttJiuistraror <br />City of Aden Hills <br />1245W."High~y% <br />;\rd...Hills, MN SSlU <br /> <br /> <br />Ji\<;;KIj; A. GRll'2'" <br />~.Public <br />Minnesota <br />MyCommiSSiollExpiresJafTuaf\'31llJOB <br /> <br />APPLICANT: PLEASE RETURN FORM TO <br />ClTYQF ARDENBILl.S, 1145 WESTHIGHWAY96..MWENHlLl.SMN 55112 <br /> <br />l.-d <br /> <br />mopa~s P~^t?[l <br /> <br />dl.S'lO SO 10 qa.ol <br /> <br />01>B1-EBl.-E9l. <br />