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<br />, <br />. <br /> <br /> <br />CITY OF CENTERVILLE <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br /> <br />Punuant to Minnesota State Statute ~13.05, Subel. 4 <br />Minnesota Data Practices Act <br /> <br />TO: City of Centerville <br /> <br />I, ~I ~,~ ~oo ~. hereby authorize and grant my informed consent to <br />permit you, DCA, FiJI, NCIC, Department of Motor 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. apd 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 CentervillelCentennial Lakes Police <br />Department or their agents to have ~ to this information, is to detamine my <br />qualification for a city license. <br /> <br />This authorimion shall be valid for a period of one (I) 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 />. ed fthat fi <br /> <br />: :~ <br /> <br />k? .:to., 07 <br />Date <br /> <br /><<\\~ ~~~\~ 1600 M~~ CSr~~..z..-\Dl <br />Full Name Printed: First Middle Last Date of Birth <br /> <br />f :\q:,~':~'n . -~~\-l~," !.'f [lri\-e(:;: Lit'~~r~'.(~) <br /> <br />h_,_., RECEIVED <br />NOV D 1 ZOOT <br /> <br />CENTERVILLE, MN <br />