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Name:' <br />h <br />Sex:. 0. MaIe ❑ Female Age: : <br />Bite& <br />Color: <br />Applicant Signature: <br />Data Practices Advisory (Tennessen Warning) <br />Date: <br />I understand that.sotrttr of the information provided on this form will -be public. data. Public data is available tg anyone who makes a <br />request for such information, Under.th'e. Minnesota Data Practices Act, your address, email and/or telephone number are. private data. <br />You may choose:not.to provide some or all of this. private data, .but'it maycause your. dog license request to be denied...By.completing <br />this information, yowat.i consenting to. allow the City of Gem Lake staff to share this information.in order to administer Gem Lake <br />.Ordinances. regarding dog licensing/ Please sign below to afi"irm-tha[ you'fiave read this notice. <br />Applicant Signature: Date::. <br />Office Use. Onlw <br />Canine:#1 <br />' <br />Dog License Tag No. <br />Rabies Tag No. <br />Amount Paid: <br />0 Cash O Check ' <br />Canine 0 <br />Dog License Tag. No. <br />Rabies Tab No.. <br />.Amount: Paid: <br />❑ Cash 0 Check <br />Canine #3. <br />Dog tjoqpse Tag No. <br />Rabies Tag No.. i <br />Amount Paid: <br />❑ Cash: O Check <br />of Dorn Lake <br />