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<br />CITY OF CENTERVILLE <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br /> <br />Pursuant to Minnesota State Statute 13.05, Subd. 4 <br />§ <br />Minnesota Data Practices Act <br /> <br />TO: <br />City of Centerville <br /> <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 city license. <br /> <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 /> <br /> <br /> <br />Signature Date <br /> <br /> <br /> <br />Full Name Printed: First Middle Last Date of Birth <br /> <br /> <br /> <br />(Attach Copy of Driver’s License) <br />