Laserfiche WebLink
10. As the person executing this application for this license, I ackno�rvledge that an investigation wili b� <br /> conducted for use in determining my qualifications. I hereby expressiy authorize release of any and all <br /> information which any organization, company or person may have, including information of a <br /> confidential or privileged nature. I hereby release the City and any organization, company or person <br /> furnishing information to the City, as expressly authorized above, from any liability for damage which <br /> may result frorn furnishing the information requested. <br /> �0. The information requested on this form will be used by the City of Orono in the issuance of your license <br /> or processing of your renewal appfication. The information that you suppiy on this form wil( became <br /> public information when received by the City of Orono. Under Minnesota law (M,S. 270.72), the City <br /> may be required to provide the business tax identification number and sociai security number of each <br /> applicant to the Minnesota Commissioner of Revenue. <br /> ANY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WfLL RESULT IN DENIAL OF THE <br /> APPLICATION. <br /> G�.� � � Ca�:��r�� <br /> (S�gnature) (Title} <br /> Subscribed and sworn to before me this <br /> (notary stamp) �� �� � <br /> �.r�=�:�.�.=v k,;:,:,;>s��;_:a;;:;.�., <br /> �.�.;�f,<.�,,:f�,.;,,�;�,�����r:� � a day of �� 1�� �l�. , 20�. <br /> �.. t� �. <br /> � �:;,� ��ar �ltti\`J li�'iLL7�l��a � <br /> �" a�y�� la�.�� <br /> � �IOTAn;PU' It nAINt�ltSOTh1 • .F.j' <br /> ��„��,�,f,s�` ��,�r„�n��u iu� E,,i�e� )Zr� �1,2019� i % �r ,�� <br /> ` S � ,,:,�,.�T��YYeau*rh �°v��"� d �-° <br /> �sr'y^��^^,2�:.;i_��:'.>Y? +'L-:,i <br /> (Notary Pubiic/City Clerk) <br /> i�� �10�A��iIVa��I i �G6-�. d`�����'10�'�(-�'� �a�'3. ���1/1L�`�d"�� ��L�191��� f-e� ���@ �F 6�-1S� ��'F��l�!-��"I��, <br /> :�. k� <br /> .� . <br /> � <br /> � .. <br /> � <br /> � i+ ;3 r' �= P.mount: '�i�'�'� '� =' Pecei t Rio.: �`i J s'.. �, <br /> �?� , �,���: Date Fee Paid: ,� - � P � _� <br /> o .. ��, <br /> Qate Counci� Approved: License No.: <br /> � <br /> y�_ , ,.�,. <br />