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ATTACHMENT C-2 <br /> CITY OF MOUNDS VIEW <br /> GENERAL AUTHORIZATION AND RELEASE <br /> PURSUANT TO MINNESOTA STATUTE 13.06 SUBD.4 110 <br /> MINNESOTA DATA PRACTICES ACT <br /> TO: City of Mounds View Police Department and <br /> Minnesota Bureau of Criminal Apprehension <br /> I, , hereby authorize and grant my informed consent to permit <br /> you to release to and make available to the City of Mounds View, Minnesota and/or its agents and/or <br /> representatives data classified as private which concerns me and which may be in your possession. <br /> The data which I authorize to be released consists of private data as defined by Minnesota Statute <br /> 13.02, subdivision 12, and has been collected by you as a result of my contacts and associations with <br /> you and/or your representatives. The information for which release is authorized is criminal history <br /> information about me that is collected or maintained by the Bureau of Criminal Apprehension and that <br /> relates to a background check crime as defined in Minnesota Statutes, Section 299C.61, subdivision <br /> 2. I understand that the purpose of permitting the City of Mounds View to have access to this <br /> information is to determine my suitability for volunteer work with that city. I further understand that <br /> this information may subsequently be utilized for other purposes relating to my possible volunteer <br /> work with the city, including verification of my records and analysis by consultants to the city who <br /> may review my suitability for volunteer work. <br /> By signing this authorization,I hereby release the Bureau of Criminal Apprehension from any and all <br /> liability which otherwise may or does accrue as a result of the release of any and all data, regardless <br /> of its accuracy. I also release the City of Mounds View from any and all liability for its receipt and <br /> use of data received pursuant to this consent. <br /> This authorization shall be valid for a period of one year, but I reserve the right to, at any time prior <br /> to that expiration, cancel the written authorization by providing written notice to the City of Mounds <br /> View or to you of that fact. <br /> (Signature) (Date) <br /> (Print Name: First, Middle, Last) (Date of Birth) <br /> • (Address) <br /> Subscribed and sworn to me before this day of , 1996 <br /> Please return to: <br /> City of Mounds View <br /> Attention: Personnel Department <br /> 2401 Highway 10 • <br /> Mounds View,MN 55112-1499 <br />