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<br />NOTIFICATION FOR LICENSE INVOLVING PRIVATE <br />OR CONFIDENTIAL INFORMATION <br />(Includes Tennessen Warning) <br /> <br />In connection with your request for a license, the City has asked that <br />you provide information about yourself which is classified as private, <br />confidential, nonpublic, or protected nonpublic under the Minnesota <br />Government Data Practices Act. This means that this data is not <br />ordinarily available to the general public. Accordingly, the City is <br />required to inform you of the following: <br /> <br />1. <br /> <br />The purpose and intended use of the information requested is to determine if you <br />are eligible for a license from the City of Centerville. <br /> <br />2. <br /> <br />You are not legally obligated to supply the requested information. <br /> <br />3. <br /> <br />The known consequence of supplying the requested information is that the <br />information of further investigation could disclose information which could <br />cause your application to be denied. <br /> <br />4. <br /> <br />The known consequence of refusing to supply the requested information is that <br />your request for a license cannot be processed. <br /> <br />5. <br /> <br />A criminal charge, arrest, or conviction will not necessarily bar you from <br />obtaining a license with the City, unless the conviction is related to the matter <br />for which the license is sought, according to Minnesota Statute 364.03. <br />However, failure to reveal the requested criminal information will be considered <br />falsification of the application and may be used as grounds for the denial of the <br />application. <br /> <br />6. <br /> <br />Other governmental agencies necessary to process your application are <br />authorized by law to receive the information provided. <br /> <br />7. <br /> <br />The City is required by law to furnish some of the information to the <br />Department of Labor (jidlhcl~try.. . and the Minnesota Commissioner of <br />Revenue. .'. <br />., <br /> <br /> <br />Duri~g the appli~ation ~ocess, your nii1~.~e and addre~s ma~ be relea~ed to the <br />pubbc. If the hcense 1&\ granted, all the. data supphed will be available for <br />inspection by the public. \ \ <br />\ \ <br /> <br />8. <br /> <br />\ <br />\ \ <br />'\ \ <br />The undersigned, by signing this notice, aclrnowl~dges that he/she has <br /> <br />understood the contents of this notice and h\ received\p copy of this notice. <br />i <br />, <br />1 <br />! <br /> <br />?-I'\ <br />Dae <br /> <br />'LCd 'lOW <br /> <br /> <br />~/ <br />