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<br />NOTIFICATION FOR LICENSE INVOL VING PRIVATE <br />OR CONFIDENTIAL INFORMATION <br />(Includes Tennessen Warning) <br /> <br />In connection with y(}ur request for a license, the City bas asked that <br />you provide information about yourself which is classified as private, <br />confidential, nonpublic, or protected nonpublic under the Minnesota <br />Government Data Practices Act. This means that this dat'a is not <br />ordinarily available to the general public. Accordingly, the City is <br />required to inform you of the following: <br /> <br />], The purpose and intended use orthe inrom1ation requested is to detem,ine if you <br />are eligible for a license from the City of Centervilk <br /> <br />2, You are not legally obligated to supply the requested information, <br /> <br />3, The known consequence of supplying the requested information is that the <br />information of further investigation could disclose informatiQn which could <br />cause YQur applicatiQn tQ be denied, <br /> <br />4, The knQwn consequenee Qf refusing tQ supply the requested infQrmatiQn is that <br />your request for a license cannot be processed. <br /> <br />5. A criminal charge, alTest, or conviction will not necessarily bar you from <br />obtaining a license with the City \ unless the conviction is related to the matter <br />for which the license is sought, according to Minnesota Statute 364,03, <br />However, failure to reveal the requested climinal information will b~ considered <br />falsificatiQn of the application and lllay be used as grounds for the denial of the <br />applicatiQn, <br /> <br />6. Other governmental agencies necessary to process your application are <br />authorized by law tQ receive the infOlwatiQn provided, <br /> <br />7, The City is required by law tQ furnish SQme of the infoffi1ation to the <br />Department of LabQr and Industry and the MinnesQta CommissiQner of <br />Revenue. <br /> <br />8. During the application process, your name and address may be released to the <br />public, If dle license is granted, all the data supplied will be available for <br />inspectiQn by the public. <br /> <br />The unde}~,igned, by signing this notice, ad:nowledges that he/she has read and <br />understood the contents of this notice and has received a copy of this notice, <br /> <br />i~(i' /. ~tJJ a~ <br /> <br />Date S lature <br />