Laserfiche WebLink
<br /> <br />CITY OF CENTERVILLE <br /> <br />GENERAL AUTHORIZATION AND RELEASE <br /> <br />Pursuant to Minnesota State Statute ~13.05, Sabel. 4 <br />Minnesota Data Praetices Act <br /> <br />TO: City of Centerville <br /> <br />1, }/{ t C. ~ / r W A-l/V1 A7l _ hereby authorize and grant my informed consent to <br />permit you, BCA, FBI, NCIC. Department of Motor Vehicles, and the City ofCenteMlle <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 iI3.02. 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 />fo~ which in any way relates to my dealings witb 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 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 resenre the right to, at <br />any time prior to that expiration, cancel tbe written authorization by providing written <br />notice to the City of Centervi11elCentennial Lakes Police Department or their agents as <br />{f ~ 15-1 <br /> <br />I 0 . 5 I. 7 <br /> <br />Date <br /> <br />. <br /> <br /> <br /> <br /> <br />~~. I <br /> <br />/1, c/~( 1lIoMII1 <br />Full Name Printed: First <br /> <br />&~ <br />Middle <br /> <br />Last <br /> <br />7-l-r,7L- <br />Date of Birth <br /> <br />(.:".' , "'1': ( ",. ..; )",; ....~. !_'.ccnse) <br />