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n ttrviik., <br />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 />'2 I, —�T, , hereby authorize and grant my informed consent to permit <br />you, BCA, FBI, NCIC, Department of Motor Vehicles, and the City of Centerville to release to <br />and make available to the City of Centerville/Centennial Lakes Police Department or their agents <br />as assigned, data classified as private which concerns me and which may be in your possession. <br />The data which I authorize to be released consists of private data, as defined by Minnesota State <br />Statute §13.02, Subd. 12, and has been collected by you as a result of my contacts and/or <br />associations with you and/or your agents and representatives. The information for which release <br />is authorized includes all data which has been collected, created, received, retained or <br />disseminated in whatever form, which in any way relates to my dealings with you or your <br />agency. I understand that the purpose of permitting the City of Centerville/Centennial Lakes <br />Police Department or their agents to have access to this information is to determine my <br />qualification for a massage therapist application. <br />This authorization shall be valid for a period of one (1) year, but I reserve the right to, at any <br />time prior to that expiration, cancel the written authorization by providing written notice to the <br />City of Centerville/Centennial Lakes Police Department or their agents as assigned of that fact. <br />4 <br />Full Name Printed: F� Middle L st <br />11- L <br />Date <br />Z- \-L-a6 <br />Date of Birth <br />SWORN TO AND ATTESTED BEFORE ME THIS DAY OF 'r <br />