2008-02-13 CC Packet - Laserfiche WebLink

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CITY OF CENTERVILLE AJI ~~ qj?D o 1/1 ~6\' GENERAL AUTHORIZATION AND RELEASE Pursuant to Minnesota State Statute ~13.05, SuM. 4 Minnesota Data Practices Act TO: City ofCeQtl:rville ~<tf'.~~ tfD <....DIC\~ . hereby authorize and grant my infornled consent to permit you, BCA, FBI, NCIC, Department of Motor Vehicles, and the City ofCenterville to release to and make available to the City of CentervillelCentennial Lakes Police Department or their agents as assigned, data classified as private which concerns me and which may be in your possession. The data which I authorize to l1e released consists of private data, as defined by Minnesota State Statute ~ 13.02, Sub<!. 12, and has been collected by you as a result of my contacts andlor associations with you and/or your agents and representatives. The information for which release is authorized includes all data which has been collected, created, received, retained or disseminated in whatever foon, which in any way relates to my dealings with you or your agency. I understand that the purpose of permitting the City of CentervilleJCentennial Lakes Police Department or their agents to have access to this information, is to determine my qualification for Iiquorltobacro licensing. This authorization sha11 be valid for a period of one (1) year, but I reserve the right to, at any time prior to that expiration, cancel the written authorization by providing written notice to the City 'IIe/Centennial Lakes Police Department or their agents as ~ "'" 0 AII'[) <:lJJ~80N Full ame Printed: First Middle Last n.,' 1:).3/ ell (o /2-1 /Yz- , I Date of Birth '. ; ~,) \ Q'" KATHLEENKTRANOEM . .J.' NotalY Public -, .. ,Minnesola ~ .. j Ccmm,,,,,,,, E""" J"vary 3J. 2011 -40-