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<br />NOTIFICATION FOR LICENSE lNVOL VING PRIVATE <br />OR CONFIDENTIAL INFORMATION <br />(Includes Tennessen Warning) <br /> <br />In connection with your request for a license, the City has asked that <br />you .provide infor~ation ab"out yourself which is classified as private, <br />confidential, nonpublic, or protected nonpublic under the Minnesota <br />Government Data Practices Act. This means that this data is not <br />or~inarily available to the general public. Accordingly, the City is <br />required to inform you of the following: <br /> <br />I;' The purpose and intended use of the information requested is to determine if you <br />are eligJ.1>le for a license from the City of Centerville. <br /> <br />2. Yon are not legally obligated to supply the requested information. <br /> <br />3. The known consequence of supplying tJ1e requested information is that the <br />information of further investigation could disclose information which could <br />cause your application to be denied. <br /> <br />4. The known consequence of refusing to supply the requested information is that <br />your request for a license cannot be processed. <br /> <br />. S. A criminal charge, ~ 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, Mure to reveal the requested crimiDa1 information will be considered <br />falsification of the application and may be used as grounds for the denial of the <br />application. <br /> <br />6. Other governmental agencies necessary to process your application are <br />authorized by law to receive the information provided. <br /> <br />7. The City is required by law to furnish some of the information to the <br />Department of Labor and Industry and the Minnesota Commissioner of <br />Revenue. <br /> <br />8. During the application process) your name and address may be released to the <br />public. If the license is granted, all the data supplied will be available for <br />inspection by the public. <br /> <br />The undersigned, by signing this notice, acknowledges that he/she has read and. <br />understood the contents of this notice and has received a copy of this notice. <br /> <br />/0-//- of <br />Date <br /> <br />~AWo-lt <br /> <br />Signa e <br /> <br />61 <br />