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CITY OF CENTERVILLE <br /> GENERAL AUTHORIZATION AND RELEASE <br /> Pursuant to Minnesota State Statute §13.05, Subd. 4 <br /> Minnesota Data Practices Act <br /> TO: City of Centerville <br /> I, , hereby authorize and grant my informed consent to <br /> permit you, BCA, FBI, NCIC, Department of Motor Vehicles, and the City of Centerville <br /> to release to and make available to the City of Centerville/Centennial Lakes Police <br /> Department or their agents as assigned, data classified as private which concerns me and <br /> which may be in your possession. The data which I authorize to be released consists of <br /> private data, as defined by Minnesota State Statute §13.02, Subd. 12, and has been <br /> collected by you as a result of my contacts and/or associations with you and/or your <br /> agents and representatives. The information for which release is authorized includes all <br /> data which has been collected, created, received, retained or disseminated in whatever <br /> form, which in any way relates to my dealings with you or your agency. I understand <br /> that the purpose of permitting the City of Centerville/Centennial Lakes Police <br /> Department or their agents to have access to this information is to determine my <br /> qualification for a transient merchant; peddler information/application. <br /> This authorization shall be valid for a period of one (1) year, but I reserve the right to, at <br /> any time prior to that expiration, cancel the written authorization by providing written <br /> notice to the City of Centerville/Centennial Lakes Police Department or their agents as <br /> assigned of that fact. <br /> Signature Date <br /> Full Name Printed: First Middle Last Date of Birth <br /> 35 <br />