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City of St. Antho.ay <br />General Authorization aid Release <br />Pursuant: to Mirviesota Stature 13.05 Subd. 4 <br />Minnesota Data Practices Act <br />To: <br />I,� � t,A � , � I t to ilii ,hereby authorize and. grant my informed. consent to permit <br />you to release to and make available to the City of St. Anthony, Minnesota and/or its <br />C and/or representatives data classified as private which concerns me and which may <br />ben your. possession. The data, which I authorize to be released, consists ofprivate data, <br />as dencd by Minnesota Stat -Lite 13.02, Subd. 12, and. has been collected by you as a <br />result of my contacts and associations with yon r and/or your agents and representatives. <br />The information for which release is authorized includes all data which has been <br />collected, created, received, retained, or disseminated in whatever form which in any way <br />relates to my dealings with you or your, agency. I understand that the purpose of <br />permitting the City of St. Anthony to have access to this in is to determine by <br />suitability for am intoxicating liquor and wine license. <br />This authorization shall be valid for a period of one year, but I reserve the right to, at any <br />time proper to that expiration, cancel the written authorization by providing written <br />notice to the City or to you of that fact. <br />'4�� i�� OL4-- j��- a 3 -'ao <br />�Signn )ure) (Date) <br />