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Form #4 <br />CANNABINOIDS LICENSE APPLICATION AUTHORIZATION <br />OF RELEASE OF DATA <br />In order to comply with State and Federal Data Privacy Acts, the City of Lexington is required to ask the <br />following information. This authorization expires one year from date of application. <br />Personal Information <br />First Name: <br />Middle Name: <br />Last Name: <br />Date of Birth: <br />Email Address: <br />Street: <br />City: <br />Address of <br />Residence: <br />State: <br />Zip: <br />Driver's License # State of <br />Issue: <br />Day Telephone: <br />Evening Telephone: <br />Business Information <br />Business Name: <br />Business Phone: <br />Have you ever been convicted of any crime, either felony, gross misdemeanor, or misdemeanor? <br /> Yes; No. If yes, please state nature and location of offense(s): <br />Have you ever been convicted of any traffic offense? <br /> Yes; No. If yes, please state nature and location of offense(s): <br />I, the undersigned, have made a license application with the City of Lexington. Realizing the City has need to <br />investigate my background and history in order to better evaluate my application, I hereby authorize and request <br />every law enforcement official and every other person, firm, officer, corporation, association, organization or <br />institution having control of any documents, records or other information pertaining to me to furnish the original or <br />copies of any such documents, records and other information to the City, and to permit said City or any of its <br />representatives to inspect and make copies of any such documents, records and other information. I further authorize <br />any such persons to answer any inquiries, questions or interrogatories concerning the undersigned which may be <br /> <br />