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<br />. <br /> <br />i& <br /> <br />CITY OF CENTERVIILE <br /> <br />GBNERALAtJTBOlUZA110N AND lIRT.1P....- <br /> <br />Punkldd .. JWhm..ca State S.eur.113.05, SuIJd. 4 <br />lWId..... Data Pndlns Act <br /> <br />TO: .City ofC8lltlrfiDe <br /> <br />r. J{\;~ ~ - hereby GtJtori7A ad 811Dt.. hdiww-t GOJISIIdto <br />permit you. BCA. FBI. NCIC. Depaa~'''"at ofMotorVe1Uo1es. aDd... as, ofCeDtlnille <br />to __ to _ make amdIable to ... Cily of ~''''',,'1aJ LIkes Police <br />De,allaat or their.. as ~ cIata .-.nfI'" as pdfttI wIdah 0QDlWIUI_ aa4 <br />which may be ill your pass_V\. "DIe data which 1.,11.... to be reJetW' COIISists of <br />pdvate data, as .JvRl-4 by ~ State S1atate 113.02, Subd. 12, 8Dd has ... <br />ca11ectId by you IS a msa1t of... ..,....flMlf aJor ~OJIS with you aJor your <br />8JID18 8Dd ...11 piAl:.'" 1he i..R.......tioJl tor which .... js ~..,. ~ III <br />d8Ia which bas ... coDtctecI. CRIItId. receiwd, ja4I..i.... or ... ..:..~ iD whaw<< <br />form. which ill. .., W8J reJafIS to .. ct..., with you or your 8JIDC1. I tIIldersImu1 <br />that the pu&puS8 of I- ..dlti.., tie City of CentemJIe/("...~,.,...UtJ Labs PoJice <br />J)ep.tme4t or their lIpIdS to have 8CCB to 1bJs iDblMtlma. is to .......ul... IIIJ <br />cpm1if1ft1ff"1l tor a em, IiceDse <br /> <br />This athori.. shaD be ftIicI tor a period of ODe (1) year. but I ~ .,.1he ria1d to. at <br />8IlJ time pdor to duIt ~aIioD. -.eel 1Iut wdUa ,mhAft._ by proyicIiDg W1iUaD <br />notice to die City of LIkes Police Depadmeat or 1hcir .... IS <br />of1hat fact. <br /> <br /> <br />1 ~1.. 'J.. ()7 <br />Date <br /> <br />fl\\U\_' CS"~ \U.\'3h <br />Full Nmle PriDtId: FiJSt Middle Last <br /> <br /> <br />I Anach (:op~ l,r Om Cl' ~ 1,lCcnse) <br /> <br />~3 <br />