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C,k, 5 0q-2 <br />INFORMED CONSENT/BACKGROUND CHECK <br />MOUNDSJVIEW Mounds View Police Department <br />2401 Mounds View Boulevard I Mounds View MN 55112 1 763.717.4000147�ax 763.717.4019 <br />For PD use only: Date to Police Department Reviewed byi <br />Approved Denied Comments <br />Your background check may include: <br />Criminal History Fingerprinting IRS Document Check <br />Driver's License Check Photos Credit Check <br />Outstanding warrants Civil & Criminal Record Check Interview <br />ATTACH A COLOR COPY OF YOUR DRIVER'S LICENSE (FRONT AND BACK) <br />PLEASE PRINT LEGIBLY <br />License Being Applied For: <br />Liquor License Massage Therapy License <br />Peddler/Solicitor/Transient Merchant Cigarette -Tobacco License <br />Lawful Gambling Premises Permit Other: <br />Business/Organization Name r Lt` }" G Phone <br />Business Address I [? 0I41 City A'I2q <br />State Zip Z y <br />First/Middle/Last Name ofApplicant: I't. t CeIJ Id DOB: <br />Maiden/Alias <br />�h <br />Applicant Home Address X -.3 6' L__0, /�j it) 14 44 A <br />Applicant's Personal Phone Email +J '-` �.� L7 �I , <br />tt 1 [• <br />Driver's license, state identification or military IDJ : �� ���� �r Sex M F ❑ <br />I authorize the Mounds View Police Department, the Minnesota Bureau of Criminal Apprehension, and the Department of Public Safety to release <br />criminal history data and traffic record data to the City of Mounds View. I understand the information provided in this form may be considered <br />private or confidential data. I further understand that I may not be required by law to provide such information. The purpose of providing such <br />information is to aid the City in its determination on said application. I acknowledge that providing, or failing to provide, such information may <br />affect the City's determination on said application. I understand this information will be made available to the City of Mounds View, its City Council, <br />agents and representatives, as well as the Minnesota Department of Revenue, the Internal Revenue Service, or any other person or entity <br />authorized by law to receive said information. I release the City of Mounds View from any and all liability for its receipt and use of data received <br />pursuant to this application. <br />NOTARIZATION REQUIR�D <br />Applicant's Signature X/�J?.�•� �� --` —_ _ ���+�.�M <br />STATE OF MINNESOTA -'.s State of Minnesota <br />COU NTY OF �� rn i MYsslon Expires <br />`� ;.• January 31, 2027 <br />Subscribed and sworn before me this day of r . 20J3 by r � 1 6cq _ <br />who proved to me on the basis of satisfactory evidence to be the person who appeared before me. <br />Nota nn <br />rY Public W w My Commission Expires: <br />