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<br />, <br /> <br />NOTIFICATION FOR LICENSE INVOLVING PRIVATE <br />OR CONFIDENTIAL INFORMATION <br />(Includes Tennessen Warning) <br /> <br />. <br /> <br />. In connection with your request for a license, the City has 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 data is not <br />ordinarily available to the general public. Accordingly, the City is <br />required to inform you of tbe following: <br /> <br />L The purpose and intended use of the information requested is to detennine if you <br />are eligible 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 COllSeqUellce of supplying the requested information is that the <br />information of further investigation could discIose information wbich could <br />cause your application to be denied. <br /> <br />4. <br /> <br />The known consequence of refusing to supply the requested information is that <br />- yourrequesrfQt1l~li~se1-'<)..lorbep!:oces!!!'!l__ '-----'_ ---"--~._~ c -- =c..- <br /> <br />5. <br /> <br />A criminal charge, lI1TeSt, or conviction will not necessarily bar you from <br />obtaining a license with the City, unless the conviction is reIated to the matter <br />for which the license is sought, according to Minnesota Statute 364.03. <br />However, failure to reveal the requested criminal information will be considered <br />falsification of the application and may be used as grounds for the deniaI of the <br />application. <br /> <br />-- --~ --.:::: <br /> <br />-,- --- ------ - --- <br />_....~..~~.--=------------------ <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 infonnation 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, aclmawledges that he/she has read and <br />understood the contents of this notice and has received a copy of this notice. <br /> <br />-rQt;~t/ <br /> <br />~&~ <br /> <br />Date <br />