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<br /> <br />CITY OF CENTERVILLE <br /> <br />GENERAL AUTIlORIZA TION AND RELEASE <br /> <br />Pursuant to Minnesota State Statute ~13.0S, Subd. 4 <br />Minnesota nata Praetices Ad <br /> <br />TO: City ofCenterville <br /> <br />I, ~nD s.~ . hereby authorize and grant my informed consent to <br />permit you, BCA, FBI, NCIC, Department of Motor Vehicles, and the City ofCenterville <br />to release to and make available to the City of CenterviJle/CentenniaJ 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 CenterviUelCentennial 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 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 />assigned of that fact. <br /> <br /> <br />\ ~ \, l i}. <br /> <br />Date <br /> <br />~ , C _ __ _ <br />looo M \c-loWr~l. ~N <br /> <br />Full Name Printed: First Middle Last <br /> <br />t,h.{b€t <br />Date of Birth <br /> <br />{ _.:" ; : .." <br /> <br />Nav 0 f 200~ <br /> <br />CENTERVILLE, MN <br />