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CITY OF GEM LAKE, MN <br />City Hall - 4200 Otter Lake Road <br />Gem Lake, MN 55110-3763 <br />Telephone 651-747-2790/2792 <br />E-mail C_ily gemlakeMl_. <br />release of Information Authorization <br />When fil ing .out #his form please print. Thank you. <br />Last Name of Applicant - -- <br />Middle (d1l). <br />Maiden, Allias or Former: <br />Current. A dress:: <br />Date of Bi the Month/Day/Year <br />Sex (M or h;,'LL <br />I,. the.abc)vf named applicant, authorize the City of .Gem Lake to xequest a computerized criminal <br />history sea ch in my name through the City of White Bear Lake Police Department and/or the <br />Minnesota Bureau. of Criminal Apprehension, pursuant to 1VIinrZesota Statutes, Section.$64.03, <br />relating to i ay application for a peddler, solicitor or transient merchant. Additionally; I authorize <br />theMinnes ta.Bureau of Criminal Apprehension and the City of White. Bear Police. Department <br />to disclose all criminal history record information to the City of Gem Lake for the purpose of <br />completing my. application. <br />This: authorization request form shall expire one year from this. _] day of <br />2015. <br />Jrgnature y Date <br />Peddler, So, icitor or Transient Merchant License Application Form: Page 4 <br />