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MounmTA <br />ViLw <br />INFORMED CONSENT/BACKGROUND CHECK <br />Mounds View Police Department <br />2401 Mounds View Boulevard l Mounds Vlew MN 55112 1783.717.4000 1 Fax 753.717.4019 <br />For PD use only: Date to Police Department 05114l2024 Reviewed by_-.�� <br />XApproved Denied Comments <br />Your background check may include: <br />r Criminal History ■ Fingerprinting ■ WS. 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 BACKI <br />PLEASE PRINT LEGIBLY <br />License Bttirt pplied For: <br />Liquor License Massage Therapy License <br />Peddler/Solicitor/Transient Merchant Cigarette -Tobacco License <br />Lawful Gambling Premises Permit Other: <br />ausiness/organrratian Nami e <br />Business Address 61 Stewart Ave ❑elran, NJ 08075 <br />First/Middle/Last Name ofApplicant: Arving J Smith <br />��laidenlfti4i.><s <br />Applicant Home Address 301 76th Ave. N Brooklyn Park, MN 55444 <br />Phone 6127034300 <br />City Minnesota State MN Zip 55444 <br />Applicant's Personal Phone 6127034800 Email arvingjallahOgmail.com <br />Driver's license, state identification or military I _ <br />DOB: <br />Sex M �X F 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 provlding 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 he 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 REQUIRED <br />Applicant's Signature X Date 05/0312024 <br />STATE OF MI NESOTA LuAnn L O'Connell <br />COUNTY OFK,FiMSSIA NOTARY PUBLIC <br />MINNESOTA <br />ti Fl Comm Gres 1 n 3' . N A <br />Subscribed and sworn before me this day of �4L{ , 20 *' <br />who proved to me on the basis of satisfactory evidence to he the person who appeared before me. <br />Notar ubllc My Commission Expires: O't 3 ira <br />