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City of St. Anthony <br />General Authori.zati.on at.M Release <br />Pursuant to Minnesota Stature 1.3.05 Subd. 4 <br />Minrtesota DmaPracti.ces Act <br />)fl��L� �)zii9u1 <br />hereby authorize and grant: my info rued consent to permit <br />a in Acase to and make availaule into City of St. Anthony, Minnesota and/or its <br />ni�_ anTor i cpresC iaiiVTea data classified as Ovate which cmamus no an,dwhich nny <br />your poswuhm. 17he aa' a, WnOh 1 al horko to be ieleasud, consists of ivate data, <br />W. nec by Minmcs ttr Statute 13M, Subd. 12, and has been. collected by you as a <br />oi'i , coj:nacts arni associations with your and/or your agents Pne! i p ser:�:a,tir�es. <br />A he infonraiJon for vh c h releasn is au how recd ar;c1 nd^s all da i which has been <br />CoRno" acted, received, retained; or dissenakated in whatever form which in any way <br />to Iny 6,eahngs wit$ you or your agency. 1 understand that the purpose of <br />Porr . hies. the City of St. Anthony to have access to this in:forrnation is to dcternune by <br />bi'i[y for an intoxicating liquor and wine license, <br />!,is ar.Quniaaiiou shall be valid for a period of one year, but T reserve the right to, at any <br />to that expiration, cancel the written authorization by providing written <br />the City or to yo -a of that fact. <br />(Date) <br />E <br />