Laserfiche WebLink
<br /> <br />CITY OF CENTERVILLE <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br /> <br />Pursuant to Minnesota State Statute U3.0S, Subd. 4 <br />Minnesota Data Pradices Act <br /> <br />TO: City ofCenterville <br /> <br />I, ~~ ~w."w . hereby authorize and gnnt my iDfurmed CODSeDI to <br />permit au, BC I, NCIC, Department of Motor Vehicles, and the City ofCenterv1l1e <br />to release to and make available to the City of CenterVillelCentennial 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 />fonn, which in any way relates to my dealings with you or your agency. I understand <br />that the purpose of permitting the City of CentervilJelCentennial 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 sball 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 CentervillelCentennial Lakes ponce Department or their agents as <br /> <br />. . .......:.........- <br /> <br />ID <br />Date <br /> <br /> <br />-z.ool <br /> <br />~iU Lee.. R~L~lL' <br />Full Name Printed: First Middle Last <br /> <br />1I <br />Date <br /> <br /> <br />1'\ r'! ~ <br />