Laserfiche WebLink
Attachment C-2 <br /> CITY OF MOUNDS VIEW <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 /> , 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, Subd.12, and has been collected by you as a result of my contacts and associations with you <br /> and/or your representatives. The information for which release is authorized includes all data which <br /> has been collected, created, received, retained, or disseminated in whatever form which in any way <br /> relates to my dealings with you or your agency. I understand that the purpose of permitting the City <br /> of Mounds View to have access to this information is to determine my suitability for volunteer work <br /> with that city. I further understand that this information may subsequently be utilized for other <br /> purposes relating to my possible volunteer work with the city, including verification of my records <br /> and analysis by consultants to the city who 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 />