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f <br />City of St. Anthony <br />3301 Silver° Lake Road <br />St. Anthony, MM 554.1$ <br />Authorization for release of Information <br />I hereby authorize the release to the City of St. Anthony, Police Department and its <br />agents any information about my personal or financial affairs and any TSCA criminal <br />records ghat maybe requested. of individual or companies with lcuowlcdge thereof. This <br />infornation, 1. understand, will be necessary in support ofmy application for an <br />intoxicating liquor and wine license. <br />I hereby release the City of St. Anthony, the Police Department and its agents, any <br />organization, company or person funzishing information to the City of St. Anthony from <br />any liability for damage, which may result from furnishing the information requested - <br />.1 <br />declare that the information 1 have provided on the Lquor and wine i,icensc ak pi canon <br />is truthful, complete, and. comprehensive slid I authorize the City of St. Amb.orry to <br />investigate the information on th s application. I also authorize copies of this document <br />0 be as vali.d;as th,e origiAls. <br />(Signator e) <br />' IN LF -c 5-rvvi- _.-- <br />(Print full narrre: last, first, middle) <br />Date of Birth: _J. - 2=igSCn.__.... <br />Subscribed and sworn to before me this _ ,�J"C-f ___day of NOVLl ukv _, 20 Ll <br />(Signaire o� � <br />SOW ANNE L. ABERNATHY <br />r a <br />Notary Public Corurty, ) ' ��^State. <br />My Commission expires on.L._?yLl �� . <br />