2002-11-13 CC Packet - Laserfiche WebLink

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i ~ I , , NOTIFICATION FOR LICENSE INVOL VING PRIVATE OR CONFIDENTIAL INFORMATION (Includes Tennessen Warning) In connection with your request for a license, the City has asked that you provide information about yourself which is classified as private, confidential, nonpublic, or protected nonpublic under the Minnesota Government Data Practices Act. This means that this data is not ordinarily available to the general public. Accordingly, the City is required to inform you of the following: I. The pUl]Jose and intended use of the information requested is to determine if you are eligible for a license from the City of Centerville. 2. You are not legally obligated to supply the requested information. 3. The known consequence of supplying the requested information is that the information of further investigation could disclose information which could ,ause your application to be denied. 4. The known consequence of refusing to supply the requested information is that your request for a license cannot be processed. 5. A criminal charge, arrest, or conviction will not necessarily bar you from obtaining a license with the City, unless the conviction is related to the matter for which the license is sought, according to Minnesota Statute 364.03. However, failure to reveal the requested criminal information will be considered falsification of the application and may be used as grounds for the denial of the application. 6, Other governmental agencies necessary to process your application are authorized by law to receive the information provided. 7. 111e City is required by law to furnish some of the infonnation to the Department of Labor and Industry and the Minnesota Commissioner of Revenue. 8. During the application process, your name and address may be released to the public. If the license is granted, all the data supplied will be available for inspection by the public. The undersigned, by signing this notice, _ a,cJs;z_tzltledges that he/she has read and understood the contents of this notice and has receivi!d a copy of this notice. / OIf)~Ib.:l. Dat~ llJ/ttkit ;! du..ke_ Signature .