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M <br />City ofSt. Anthony <br />330.1 Silver Lake Road <br />St. Anthony, .MN 55418 <br />Authorization for Rclease of Information <br />I hereby authorize the release to the City of St. Anthony, Police Department and its <br />agents any infoanation about my personal or financial affairs and any BCA criminal <br />records that: may be requested of individual or companies with knowledge thereof. This <br />information, l: understand, will be necessary in support of m.y 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 />orgarnzation, company or person furnishing information. to the City of St. Anihony from <br />any liability for damage, which. rrray result from furnishing the information requested. <br />I declare tbat the information I have provided on the liquor and wine license application <br />is truthfuL compiete, and eompreliensive and I authorize tine City of St. Anthony to <br />investigate the information on this application.. I also authorize copies of this docurnen.t <br />to be as valid as the originals. <br />CL <br />(Sir aturc) <br />1Rasor,A lm14aIILIW"i`� <br />(Print full name: last, first, middle) <br />Date of Birth: — <br />Subscribed and sworn to before me this �4- <br />�3 dayof_�l�'�?-'_� _ ZtG <br />im' . ��___ <br />(Signature o£ <br />Notary) -- <br />' X60' (lCc, ANNE L ABERNftiTNY <br />shit or KANSAS M9 APPI. EXP of <br />Notary Public_ rte; _County, I1 -f S Cate. <br />My Commission expires on---�'- qyD o'� <br />