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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 Illlt): <br />-9:� ck— <br />First Name (please print) : �j' 0 <br />Middle (full)(please print): ,� yp j <br />Maiden, AIias or Forme (please print): <br />Current Address: Ah N11MOCY— -l� <br />Date of Birth: MonthMay/Year G <br />S <br />Sex (M or F):W .; <br />I, 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 />Sheriff's 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, I authorize the Minnesota Bureau of Criminal Apprehension <br />and Ramsey County Sheriff's 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 auth riz tion request form shall expire one year from this /13 day of <br />�' 20L-� P+1 <br />( Z� a& - MOh3Signature -Da <br />