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10. As the person executing this application for this license, I acknowledge that an investigation will. be <br /> conducted for use in determining my qualifications. I hereby expressly 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 liabilify for damaae which <br /> may result from furnishing the information requested. <br /> 10. 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 application. The information that you supply on this form will become <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 WILL RESULT IN DENIAL OF THE <br /> APPLICATION. <br /> �.�..l��G ����.!��I� ���,/CG9f� <br /> (Signature) (Title) <br /> Subscribed and sworn to before me this <br /> (notary stamp) , . <br /> �������-��r_,�.�_.:��� <br /> �-;,,,�,.�i-.�day of r��,,�.: ����: / <br /> . �r�� ;,� ��r��T i�,L.��K�f�f � <br /> .�`� >. , o;-t� Notary Publtc-f���innesota � <br /> 1� ��;;,,�a Comm�ssian Nfl.ua8069i t,� :,� <br /> ti PJ� Comm�ssion Expues Jan.31 2010 � -�,"- --� � � <br /> `�l. y .�e��'�s ,;r:�R:�;;�-�s=at�-f=�{, ���l .�',L .��; _ �r c,--�'vr��-..t'°-v�--'' <br /> v-";�-..s-'�"k''�v�.'.:-.y.w�a3�'m .r =�'--� --- <br /> l (Notary Public/City Clerk) <br /> ;��� ��T s�Ch�i1,(d��� FO� AD�1TI�6��� ���i����i�� ����iE��� �S P��s C9s= d Nlfi� ,��'F�La�;d�T��3i��. <br /> i <br /> �: � , � r' <br /> v��'Y !�S�: Date Fee Paid:�3:3,�iy �= P,mount: '-:'' �.'} z��� Receipt No.: % `,.� •����' �� I <br /> � � . , <br /> Date Council ,Appro���ed: License No.: <br /> i <br />