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<br /> <br />CITY OF CENTERVH..LE <br /> <br />GENERALAUTHOlUZATION AND RELEASE <br /> <br />PaN.O. to 1fi."1!IOta State SClltutafl3.85, Sabel. .- <br />/ MIIlDISOIa Data. Practices Act <br /> <br />TO: City ofCaltenDle <br /> <br />I. hereby 1dlhoai2.0 8Dd grant my iBfomlecI eollNt to <br />permit you. DCA, FBI. NCIC. DqleI1mcIIt of Motor Vehicles, lIIId the City ofCcmerviJ]e <br />to release to aud maD available to the City of ~'~Il.ltd LUa Police <br />~tw..Qt or their apntB IS .,.,tp(, cIaIa cl"";W .. private which 1lOIlC". "'" me lIIId <br />which may be in your pos8CllIiorI 'lbe data 1ItIicb I IIIItbori.ze to be released c:onaists of <br />priva1l: data, .. ~""'" by VImlCSOII State Statute 113.02. Sabd. 12, IIld has beon <br />col1ected by )'011 II a. result of my contIels lIIIIIIor ~ with youlDldlor your <br />aaeats aDd lll}4U dodives. The l'lfo-........ for which.... is """'lIlml iDclucles III <br />dala which Iw beeIlcolleetlld, ctWod. rece1vcd, ..-lned or dis8eanimlbld in wbaIcwr <br />form. which in Illy way .... to my "-1m,s. with you or your 8f1lIJI:1. I __oltl-d <br />tbat tbe JIUIPOllI' of JI"" ...:ltl'li tile City of cV'..... .iDcr'CcPt......lAl Lakes Police <br />:D&.a-btlo:l.Jl or their lIpIltI10 have IILlCelII to ... il&~',~is to dctamine my <br />fl""Ji~ iIr Jiquar/tolJecoo 1iceasiDg. <br /> <br />This .Ib>. :..otIQa sbIJ1 bnalid tbr a period of ODe (1) year, but I reserve the rlaht to. It <br />any time prior to that expit.liOll,. caoccl tbe wnttalllUlboriza!ioa by JII'O"idiD8 written <br />IlOticc \\) the City of ~tIlIl..ilJl Lakes PoliI:e ~ or their agell1S .. <br />1S8i~~~r. <br />:'~:"~~::~')~':'~<:~-::~F" '_ .,', ,.' " ",""_" ",'-:'h <br /> <br />~i~i./r <br />. - . ;;,:c.~~~,; <br /> <br />~-3-()2 <br />.....-.. <br /> <br /> <br />h-/1-77 <br />Da1l: of Birth <br /> <br /> <br />, ... l <br />Full Name Printed: Find <br /> <br />Middle <br /> <br />LIIIIt <br /> <br />.............. <br /> <br />~D <br />