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10. As the person executing this application for this license, I acknowiedge that an investigation will be <br /> conducted for use in determining my qualifications. I hereby expressly authorize release of any and a!I <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 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 social security number of each <br /> applicant to the Minnesota Commissioner of Revenue. <br /> ANY FALSIFICATION OF }�NSINERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br /> APPLICATION. ' <br /> � � <br /> �� _.._, i ��� <br /> ,.._. _ � � .. � <br /> �:•... ,.._.._......___. .:. _ <br /> ... � •. <br /> c�.-:_:,;,.�.----_`:U--- - . \, .��Q��\� <br /> ._ , _ , <br /> � <br /> _..._.,. - � <br /> __...,..._.. �`� <br /> (Signature) (Title) <br /> Subscribed and sworn to before me this <br /> (� �������� � � - . � <br /> <.F � V4'�fV�Y ?. ��t,�tP�i day of , 20 b o <br /> � �.�. r�r�r�c-�►���cm, � ,, <br /> "� htq C�n Bptkea Jsr�.9i,2010 j? . <br /> . ���v�� a <br /> , " — <br /> (N tary Public/ ity Clerk) <br /> SEE ATTI�CHi�IEPVT FOR ADDITiONAL DOCUMEfVTS REQUIRED AS PART OF THIS AP�LICtil'I�(V. <br /> C;�"Y !!S�': Date Fee Pa�d: Amo!�nt: Receipt N�.: <br /> Date Councii Approved: License No.: <br />