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Attachment C-1 <br /> CITY OF MOUNDS VIEW <br /> 410 <br /> GENERAL AUTHORIZATION AND RELEASE <br /> PURSUANT TO MINNESOTA STATUTE 13.06 SUBD.4 <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 you <br /> 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. The data <br /> which I authorize to be released consists of private data as defined by Minnesota Statute 13.02, Subd.12, <br /> and has been collected by you as a result of my contacts and associations with you and/or your <br /> representatives. The information for which release is authorized includes all data which has been collected, <br /> created, received, retained, or disseminated in whatever form which in any way relates to my dealings with <br /> you or your agency. I understand that the purpose of permitting the City of Mounds View to have access <br /> to this information is to determine my suitability for employment with that city. I further understand that <br /> this information may subsequently be utilized for other purposes relating to my possible employment with <br /> the city, including verification of my records and analysis by consultants to the city who may review my <br /> suitability for employment. <br /> 110 <br /> By signing this authorization,I hereby release the Bureau of Criminal Apprehension from any and all liability <br /> which otherwise may or does accrue as a result of the release of any and all data, regardless of its accuracy. <br /> I also release the City of Mounds View from any and all liability for its receipt and use of data received <br /> 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 to that <br /> expiration, cancel the written authorization by providing written notice to the City of Mounds View or to <br /> 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 />