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2007-11-28 CC Packet
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2007-11-28 CC Packet
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11/21/2007 2:30:06 PM
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11/21/2007 2:29:11 PM
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<br /> <br />CITY OF CENTERVlLLE <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br /> <br />Pursuant to Minnesota State Statute ~13.05, Subel. 4 <br />MiIlnesota Data Pnctices Act <br /> <br />hereby authorize and grant my informed consent to <br />, artment otMotor Vehicles, and the City of Centerville <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 bas 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 CentervillelCentenniaI 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 /> <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 CentervillelCentennial Lakes Police Department or their agents as <br />f <br /> <br />:u:.:..! -' I . _ : <br /> <br />/ ()- ;; ';2'0] <br />Date <br /> <br />f);Ul <br />Full Name Printed: First <br /> <br />aM tJ ;tZ; ,(/{A/I/' <br />Middle Last <br /> <br />g- S-Sj? <br />Date of Birth " <br /> <br />!: \'1;;' t-j; \~\,: -.. .' . ; .~. L!("cn~~i:") <br />
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