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Data Practices Advisory,(Tennessen Warning) I understand that some of the information provided on this form will be public data. Public data is available to anyone who makes a request for such information. Under the Minnesota Data. Practices Act your address, entail and/or: telephone number are private data. You may choose not to provide some or all of this private.data, but it may cause your license request to be. denied. By completing this information; you are consenting to allow the: City of Gent Lake staff to share this information in order to administer Gent Lake Ordinances regarding. Peddlers; Solicitors and Transient Merchant Iicenses. Please sign below to affirm that you have read this notice: Ap pl icafit-Si gnat u re: Date: Consent The data you furnish..on the.application will be: used by the City of Gem Lake to assess your qualifications for licensure. Disclosure of the information is voluntary.. You are not legally required to provide this data; however, if you fail to do so, the City .o.f Gent Lake may 1?attnable to process. this application. .Disclosure of -your Minnesota Tax ID ?Number, Social Security Number, .or Individual Tax ID Number is -required by Minneso%a Statutes. 270C.72; and your Social Security Number may. be requested by and released to the Minnesota Commissionerof Revenue: After submission, al l information is pursuant to Mitnesota Statutes, Chapter 13.. A SIGNATURE.IS REQUIRED IN ORDER 'TO PROCESS THIS APPLICATION I, (print Hanle) ,certify or. declare under penalty of perjury, under the laws of the State of Minnesota, that theforegoing is true: and. correct. All information given is subject to ver..ification..b the.State of Minnesota. I understand that false information may rosult.in the denial, :suspension, or. revocation of my business license. Signature: Office Use Only Date: APPLICATION MAY TAKE OP TO 10 BUSINESS DAYS TO PROCESS .D Peddler (License) 0. Solicitor (Registratidri Oniy — No Fee) C] Transient Merchant (License). Date Received: Date Review Completed:. Date Paid (If applicable)/Forth of Payment: Notes; Background Ciieck Required ❑ Yes O No.. Date Sent to P.D. Date P.D. Received: Date of Background .Check: Approved: ❑yes 0 No 'Notes:or Reason for` Denial: P. D. Signature: Title: Date: City af.Gem.Lake Peddlers, Sa]icitars and Transient Merchants License- fate 4