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M <br />Cily qfSt. Atahony <br />330.1 Silvel,-Lalce.Road <br />S1. llnlhony, MN 55118 <br />A "hw-Intion, Rcle, <br />u,,L A ase of <br />ci)y rum h Pjjoe the release to the City of &. Arithony, Police Doparlment and its <br />)r); ir-�om--",rtirPJ Shou-, niY personal or financiall affair ands my 13C A criminal <br />'1 tray l).0' y,..;.41.e d of a! or comp ;lies, with knowiecige, jricrcoj,.. 'j'Irs <br />of I wndcrsand, will he necess aj-y it, sP-ppori ol illy application for an <br />oi antJ nc hoonse, <br />1000 re%su flic Mv OfSLA-n'.11011Y, ffic POIICT- Departrienz anti its agcnts, soy <br />cnmipa'ny or icl:s011 f4TI)islIM9 of rmadon in Te My of St. AnWay Win <br />13 YOKly !,�or darnage, which nmy resull. lom ArrinShing the n1fo311n,tion <br />dhthc ink W011 i have PMvidcd on je Hijogy am] Wig Ucesso qjAcubon <br />a"id collil)1enclasive and i ailithorile to Chy of Antony to <br />ihL� infitinatio)' W1 d -S aPPHWO11. 1 also "11-thorize Copies MR doomnent <br />IUUMS <br />- le <br />luxe) <br />Panic: IS; BTS[ Addle) Doe of Birth:- <br />+tc�� ap.d sv:oln to beftire 1"Ic this /12"--layof -'ec <br />Coonty I <br />a <br />71"Won XPO's or�3 ' <br />ro� <br />CHAD kM;, M E RS �ON <br />Notary Public j <br />Minnesota <br />LMy Commission Expires Jan. 31, 2009 <br />