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<br />," <br /> <br />'~ <br />, <br /> <br />RECEIVED <br />NOY 0 2 2004 <br />NOTIFICATION FOR LICENSE. INVOLVING PRIVATE <br />OR CONFIDENTIAL INFORMATION <br />(Includes Tennessen Warning) <br /> <br />. . <br /> <br />lB. conneetion with your' request for a license, the City has asked that <br /> <br />. you provide information about yourself which is dassified as private, <br /> <br />confidential, nonpubHc, or protected. nonpubHc under the Minnesota <br /> <br />Government Data Practices Ad. This means that this data is not <br /> <br />ordinarily available to the general public. Accordingly, the City is <br /> <br />required to inform you of the foRowing: <br /> <br />.1. The purpose and ~ use of the .infurmation requested is to detemrine if you <br />are eligible for a Jic:ense from the City of 0mterviJle. <br /> <br />2. You are not lega1J.y obligated to supply the JeqUeSted .ha<aaoation. <br /> <br />3. The known ~ of supplying the requested iDlbrmation is 1bat the <br />information of further ~on could disclose information wbich could <br />cause your applica1ion to be denied. <br /> <br />4. The,known consequenc:e ofrefusiDg to supply the requested infomIation is that <br />your request for a license amnot be processed <br /> <br />S. A crimiDa1 cbarge. arrest, or conviction wiJl not ~ bar you from <br />obtaioiDg a Jicense with the City. UD1ess the c:o.nviction is m1ated to the matter <br />for which the license is sought. according to Minnesota Statute 364.03. <br />However. failure to reveal the requested crimimtl io~n mAfion wiJl be CODSideted <br />fidsification of the application aDd may be used as grounds for the denial of the <br />applica1ion. <br /> <br />6. Other 8OyC,...laenta1 agencies l1eOO!JSary to process your application are <br />a.,t1h)o i7IXJ by Jaw to m:eive the information provided. <br /> <br />7. The Ci1J is' .u;qu.iRd by Jaw to furnish some of the information to the <br />Department of Labor and Industry and the Minnesota Q)mmiMiooer of <br />Revenue. <br /> <br />8. During the applicat:ioo process. your mune and addJ:as may be Id.eased to the <br />public. If the li<:eDse is gmnted, an the data supplied will be available for <br />inspection by the public. <br /> <br />'Jheundersigne4 by signing this notice, acknowledges th(lt belshe hils real and <br />understood the contents o/this notice and has received a Copy o/this notice. <br /> <br />\\\,\~ <br /> <br />.~ \ ~6&> <br />S\prture <br /> <br />Date <br />