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C119 YOFC.ENrERVILLE <br />GENEIIIRAI., RE]IIL.,,EASE <br />Persuaut to Minnesota State Statute §13.05, Subd. 4 <br />. Minnesay ta.Date .PTactic es.Act <br />T,O" . City of Centerville <br />. ............ 1_0._�V\ ------------ herh eby autori7e and grant rayinformed coy nit <br />t t <br />permit you, BCA, FBI, NCIC, Department of tor 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 concernsine and <br />which may be in your possession, The data Which I authorize to be released consists of <br />private data, as defined by Nfinnesota 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 al.1 <br />data which has been collected, creat4. received, retained or disseminated in whatever <br />forin, which in any way relates to my dealings with you oryour 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 city license. <br />This authorization shall be valid :for a period of one (1) year, bunt .1reserve the right to, at <br />any time prior to -that eKpiraflon, cancel the written authorization 'by providing written <br />notice to the City of Cenot ervil.le/Ce:ntennial..I,akes.lPolice.Deputment or their agents as <br />assigned of thatfact.. <br />F_1�1318111111LUAC Date <br />Full Name Printed: First Nfildiffle Laqi, <br />Date of Birth <br />