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Jan 7 2005 10:09 P.06 <br />F. OTHER INFORMATION REQUIRED. Provide such other information that the City <br />shall require. <br />G. ACKNOWLEDGEMENT. The applicant has received a copy of the City's Pawn <br />Shop Ordinance and is familiar with the contents therein. Any false <br />statements shall result in the denial of the application. It is unlawful <br />to knowingly make a false statement in the license application. <br />APPLICANTS NOTE: This application will not be accepted without all <br />necessary attachments, including the bond required <br />under Section 818.070 and the site plan required by <br />Section 818.080. <br />I understand that the information provided in this application may be <br />considered private or confidential data. I further understand that I may not <br />be required by law to provide such information. The purpose of providing such <br />information is to aid the City of Little Canada in its determination on my <br />application for a permit. I acknowledge that providing, or failing to <br />provide, such information may affect the City's determination on my <br />application. I understand this information will be made available to the City <br />of Little Canada, its City Council, agents and representatives, as well as the <br />Minnesota Department of Revenue, or any other person or entity authorized by <br />law to receive said information. 1 release the City of Little Canada from any <br />and all liability for its receipt an' s r f data received pursuant to this <br />application. <br />I/ 7705- <br />Date ignature of Applicant <br />If application is by a corporation, an officer of the corporation must sign; <br />if by a partnership, a general partner must sign; or if by an incorporated <br />association, the operating or managing officer must sign. <br />Subscribed and sworn to before me <br />DIP o3r <br />JANICE K. KLINSING <br />Notary Public <br />Minnesota <br />My cormskn E <ptrvs Jen. 31.2005 li <br />FOR OFFICE USE ONLY: <br />POLICE REVIEW: This is to certify that the applicants, and the associates, <br />named herein have not been convicted of any violation of laws of the State of <br />Minnesota, Municipality or County. <br />Date <br />Signature Title <br />`CITY COUNCIL ACTION: Approve Deny Date <br />5 <br />