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INFORMED CONSENT/BACKGROUND CHECK <br />Mov�v is VIEW Mounds View Police Department <br />2401 Mounds View Boulevard I Mounds View MN 551121 7 3.717.400 ax 763.717.019 <br />For PD use only: Date to Police Department 2L 3Reviewed by <br />,roved Denied Comments l <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 & Criminai Record Check Interview <br />ATTACH A COLOR COPY OF YOUR DRIVER'S LICENSE (FRONT AND RACK) <br />PLEASE PRINT LEGIBLY <br />tin ease Being Applied For: <br />x Liquor license Massage Therapy License <br />Peddler/Solicitor/Transient Merchant x Cigarette -Tobacco License <br />Lawful Gambling Premises Permit x Other: LOTTERY Llt; <br />111vsiIless/Organization blame RASSEL WINE & SPIRITS LLG Phone 5623225069 <br />Business Address 2577 Mounds View Blvd <br />irst/Middle/1_ast Narne of App0caat: KM RASSEL ZAHIQ <br />Maiden/Alias <br />City MOUNDS VIFW ^ State MN Zip 55112 T <br />Applicant Home Address 18087 66TH PL N, MAPLE GROVE MN 55311 <br />DOB-. M_ <br />Applicant's Personal Phone Email BEVERAGEGROUP.ZAHID@GMAL.CL7M <br />Driver's license, state identification ❑rmiiitary 1 _ _ ;ex to Imo{ I I { <br />i authorize the Mounds View Police Department, the Minnesota Bureau of Crirninml Apprehension, and the Department of Puulic Sdiet:: to rr*!easw <br />criminal history data and traffic record data to the City of Mounds View. I understand the information provided in this form may IN-- consr&-red <br />private or confidential data. I further understand that I may not be required by law to provide silr-h information. Me purpose irf rroviding ,A,Lc; s <br />information is to aid the City in its determination on said application. I arvoc-wledge that providing, or failing to provide, such irttca alativn may <br />affect the City's determination on said application. i understand this inforrnatin,i 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 5p1 vice, of any other person of entity <br />authorized by law to receive said information. I release &,,!City of Mounds View from any and all liability for its i eceip: and use of data received <br />pursuant to this application. A <br />NOTARIZATION REQUIRED r <br />Applicant's Signaturex &Ck Date ri11 t[ <br />STATE OF MINNESOTA <br />COUNTY OF kul <br />.I-ii:%%cribed and sworn before rqe this „?---day of �.L �►r: 7.0 - <br />S1rr �* - <br />who proved to me on the basis of satisfactory evidence to be the person w. hra appeared k fr`�` r+i� .:. � BAABARA A $FIVE <br />NOTARY PUBLIC- MIN NESDTA <br />Notary Public__ My Commission L .1 My Cnmmissaon Erp res far 3f • 2021 - <br />