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40- CITY OF GEM LAKE, MN <br />City Hall - 4200.Dater Lake Road <br />Gem. Lake, MN 55110-3763 <br />Telephone 651-747-2790/279.2 <br />Email City@geralakeMN.org <br />Release of Information Authorization <br />When filling out this. form please print, Thank you. <br />Last Name of <br />First Name: <br />Middle (full): <br />Maiden, Alias or Farmer: <br />Current Address; <br />Date of Birth: MonWDay/Year <br />Sex {1VI or P}: <br />- -p <br />L the above named applicant, authorize the City of Gem Lake to request a computerized criminal <br />history search in my name through the City of White. Bear Lake Police Department and/or the <br />Minnesota Bureau of Criminal Apprehension, pursuant to Minnesota Statutes, Section 364.03, <br />relating to my application for a peddler, solicitor or transient merchant. Additionally, I authorize <br />the Minnesota Bureau of Criminal Apprehension and the City. of Wh te.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 au orization request form shall expire one year from this ii day of <br />20 <br />j 15 ► <br />Date <br />Peddler, Solicitor or Transient Merchant License Application Form Page 4 <br />