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M <br />City of St. Anthony <br />General Authorization and. Release <br />Pursuant to .Minnesola Stature 13.05 Subd.. 4 <br />Minnesota Data. Practices Act <br />L-3--ow`z., , hereby authorize and grant my informed consent to permit <br />you. to release to and make available to the Cily of St. Anthony, Minnesota and/or its <br />agents and/or representatives data classified as private which concerns inc and which may <br />be in your possession. The data, which I authorize to be released, consists of private data., <br />as do rood by Minnesota Stat -ate 13.02, Subd. 12, and has been collected by you as a <br />result of my contacts and associatio:o.s wif.',i your aid/or you. agents and representatives. <br />The inforination fon wEch release is autborizcd includes all data which has been <br />collected, created, received., retained, or disseminated in whatever ;:orxn which in any way <br />relates to nay dealings with you or your agency. .1 undce-stand that the purpose of <br />permitting the City of St. Anthony to have access to this information is to determin.c by <br />suitability for an intoxicating liquor and. wine license. <br />This authorization shall be valid for a period of one yeax, but I reserve the right to, at any <br />time proper to that expiration, cancel the vaitten. authorization by providing written <br />notice to the City or to you of that fact. <br />rr <br />($ip ature) � (Date) <br />