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<br /> <br /> <br />INFORMED CONSENT <br /> <br /> <br />TO: Minnesota Bureau of Criminal Apprehension <br /> Criminal Justice Information Systems – CHA <br /> 1430 Maryland Avenue East <br /> St. Paul, MN 55106 <br /> <br />FROM: City of Mounds View <br /> Attention: Personnel Office <br /> 2401 Highway 10 <br /> Mounds View, MN 55112 <br /> <br /> <br />Applicant Note: The information contained herein is considered private data, and will be used <br />only to determine your suitability for volunteering with the City of Mounds View. Providing this <br />information is strictly voluntary and you are not required by law to furnish any of the information <br />requested herein. However, if you do not furnish it we may have trouble determining your <br />suitability for volunteering with the City. The information provided herein will be accessible to <br />you, pertinent staff of the City of Mounds View, or as provided by Minnesota Statutes. <br /> <br />BCA Note: The following person below has applied for a volunteer position with the City of <br />Mounds View. City policy requires that criminal history inquiries be made on volunteer <br />applicants. <br /> <br />Full Name: ___________________________________________________________________ <br /> (first) (middle) (last) <br /> <br />Maiden, Alias or Former Name: _______________________________________________ <br /> <br />Date of Birth: ______________ Sex (M OR F): ____ <br /> <br />I authorize the Minnesota of Criminal Apprehension to disclose all criminal history record <br />information to the City of Mounds View, Attention: Desaree Crane, Assistant City Administrator, <br />for the purpose of volunteering with this agency. <br /> <br />The expiration of this authorization shall be for a period no longer than one year from the date of <br />my signature. <br /> <br />________________________________ ________________________ <br />Signature of Applicant Date <br /> <br /> <br />State of Minnesota } <br />County of Ramsey } <br /> <br />Subscribed and sworn to me this day of , 2015. <br /> <br /> <br />Notary Public Notary Stamp