HomeMy WebLinkAboutAuthorization and Release _Bus. Licenses, Mass
CITY OF CENTERVILLE
GENERAL AUTHORIZATION AND RELEASE
Pursuant to Minnesota State Statute 13.05, Subd. 4
§
Minnesota Data Practices Act
TO:
City of Centerville
I, , hereby authorize and grant my informed consent to
permit you, BCA, FBI, NCIC, Department of Motor Vehicles, and the City of Centerville
to release to and make available to the City of Centerville/Centennial Lakes Police
Department or their agents as assigned, data classified as private which concerns me and
which may be in your possession. The data which I authorize to be released consists of
private data, as defined by Minnesota State Statute §13.02, Subd. 12, and has been
collected by you as a result of my contacts and/or associations with you and/or your
agents and representatives. The information for which release is authorized includes all
data which has been collected, created, received, retained or disseminated in whatever
form, which in any way relates to my dealings with you or your agency. I understand
that the purpose of permitting the City of Centerville/Centennial Lakes Police
Department or their agents to have access to this information, is to determine my
qualification for a city license.
This authorization shall be valid for a period of one (1) year, but I reserve the right to, at
any time prior to that expiration, cancel the written authorization by providing written
notice to the City of Centerville/Centennial Lakes Police Department or their agents as
assigned of that fact.
Signature Date
Full Name Printed: First Middle Last Date of Birth
(Attach Copy of Driver’s License)
SWORN TO AND ATTESTED BEFORE ME THIS DAY OF
, 20___.
Notary Public
(Seal)