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Release of Information Authorization <br />The following named individual has applied for a license with the City of Gem Lake: <br />Last Name of Applicant (please print): <br />First Name (please print) : <br />Middle (fWI)(p]ease print): <br />Maiden, Alias or Former(please print): <br />Current Address: <br />Date of Birth: Month/Day/Year <br />Sex (M or F): <br />1, the above named applicant, authorize the City of Gem Lake to request a <br />computerized criminal history search in my name through the Ramsey County <br />Sheriffs Department and/or the Minnesota Bureau of Criminal Apprehension, <br />pursuant to Minnesota Statutes, Section 364.03, relating to disqualification for a <br />license. Additionally, 1 authorize the Minnesota Bureau of Criminal Apprehension <br />and Ramsey County Sheriffs Department to disclose all criminal history record <br />information to the City of Gem. Lake for the purpose of completing my license <br />application. <br />A copy of the license application is .attached for reference. <br />This authorization request form shall expire one year from this day of <br />?0. <br />Signature Date <br />