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INFORMED CONSENT/BACKGROUND CHECK <br />Mot�vns VIEW Mounds View Police Department <br />2401 Mounds View Boulevard I Mounds View MN 66112 i 763.717.4�1]0 _ x 763.717.4019 <br />For PD use only: Date to Police Department Reviewed by � _���_ <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 />Outstandingwarrants Clvil & Criminal Record Check Interview <br />AITACH A COLOR COPY OF YOUR DRIVER'S LICENSE (FRONT AND BACK) <br />PLEASE PRINT LEGIBLY <br />License Being Applied For: <br />7L Liquor License <br />Peddler/Solicitor/Transient Merchant <br />Lawful Gambling Premises Permit <br />Massage Therapy License <br />Cigarette -Tobacco License <br />Other: <br />Business/Organization Name 4Y, X re ' I [rI' 1 14 one <br />r w' 'I <br />Business Address _� y � CO) rd, Z - - U 6 City I7'44_ ZAr ( state z zip ;_�kl� <br />First/Middle/Last Name of Applicant: P'1'4 6;_1—eA_J �IUA AI DOB: <br />Maiden/Alias_ <br />Applicant Home Address_ .'{.7— <br />r b_ n� L C,- /V <br />Applicant's Personal Phone <br />�' .' -&G�7 Emall_.� /il/�V <br />Driver's license, state identification or military ID 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 Clty'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 entlty <br />authorized by law to receive said informatlon. I release the City of Mounds View from any and ali l abillty for its receipt and use of data received <br />pursuant to this application. <br />NOTARIZATION REQUIRE <br />77 �� <br />Applicant's Signature x " �_' L—`_ Date f _ V <br />STATE OF MINNESOTA <br />COUNTY OF _AnOY-a <br />Subscribed and sworn before me this a -1f-K day 20&4 by. I� 1CA M <br />who proved to me on the basis of satisfactory evidence to he the person who appeared before me. <br />Notary Public _ 6 MV Commission Expires: i I'1 <br />yr <br />7731 <br />HNJ <br />Illy, 2U2y <br />