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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 liability for damage which <br /> may result frorn furnishing the information requested. <br /> 10. The information requested on this form wiil be used by the City of Orono in the issuance of your license <br /> or processing of your renewai application. The information that you supply on this form wili 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 ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br /> APPLICATION. <br /> �'i' /�`.�;,� �%�;;,�=---- (� . <br /> E.G-� / �,�,r 'd (`c'�d c� ��t'�"� <br /> �, 1 ..�:ir„-..s✓;' prfFy�:'.�,h.'�;%%�L.,<°—r�ti.._. <br /> '(Signature) (Title) <br /> Subscribed and sworn to before me this <br /> (notary stamp) <br /> day of , 20 <br /> (Notary Public/City Clerk) <br /> SE� A'y"�ACHMEN� FOF� ADDlTI�PJ�aL. D�CUM�f�TS ��QldI�tED AS PARI ��= i HSS �F��L1��19�a�. <br /> � <br /> � <br /> �E�Y �5�.: Date Fee Paid: 9�� 3� �� �_ A.mount: /G� G�: �' l' Receipt No.: ��� ''��� � <br /> Date Council Approved: License No.: <br />