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<br />~ <br />~HILLS <br /> <br />. <br /> <br />CITY OF ARDEN HILLS <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br />PURSUANT TO MINNESOTA STATUTES 13,05, SUBD. 4, <br />MINNESOTA DATA PRACTICES ACT <br /> <br />To: <br /> <br />I, , hereby authorize and grant my informed consent to pennit <br />you to release to and make available to the City of Arden Hills, Minnesota, and/or its agents and/or representatives <br />data classified as private which concerns me and which may be in your possession. The data which I authorize to be <br />released consists of private data as defmed by Milmesota Statue ]3.02, Subd. 12, and has been collected by you as a <br />result of my contacts and associations Vlith you and/or your representatives. The information fOT which release is <br />authorized includes all data which has been collected, created) received, retained, or disseminated in whatever form <br />which in any way relates to my dealings with you or your agency. I understand that the purpose of pennitting the <br />City of Arden Hills to have access to this information is to determine my suitability for operating a peddler, <br />solicitors, transient merchant, andlor political canvassing operation within the City. <br /> <br />By signing this authorization, I hereby reiease the Bureau of Criminal Apprehension from any and allliabiiity which <br />othcnvise mayor does accrue as a result of the release of any and all data, regardless of its accuracy. I also release <br />the City of Arden Hills from any and all liability for its receipt and use of data received pursuant to this consent. <br /> <br />. <br /> <br />This authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to that <br />expiration, cancel the written authorization by providing written notice to the City of Arden Hills or to you of that <br />fact. <br /> <br />Signature <br /> <br />Date <br /> <br />Full Name - Printed <br /> <br />Date of Birth <br /> <br />Subscribed and sworn to be before this <br /> <br />day of <br /> <br />,20_. <br /> <br />, Notary Puhlic <br /> <br />Please return to: <br /> <br />Schawn Johnson, Assistant to the City Administrator <br />City of Aden Hills <br />i245 West Highway 96 <br />Arden Hills, MN 55112 <br /> <br />. <br /> <br />APPLICANT: PLEASE RETURN FORM TO <br />CITY OF ARDEN HILLS, 1245 WEST HIGHWAY 96, ARDEN HILLS MN 55112 <br />