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10. As the person executing this application for this license, f 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 wili 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 wiil 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 /> appiicant to the Minnesota Commissioner of Revenue. ; <br /> ANY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br /> APPLICATION. „ � <br /> � — �'!��f�.�_. <br /> �-� �_.:�,_1��-,��.---.- ��-�-- l.+Q /� ��'�G.li�'c��'1" <br /> � Title � <br /> (Signa ure) '� - �',` � ) <br /> / <br /> �' <br /> Subscribed and sworn to before me this <br /> (notary stamp) <br /> day of , 20 <br /> (Notary Public/City Clerk) <br /> SEE ATTAGHMEN� �Ol� ADDITI6�I�aL DO�U�i�i�`fS R��UI�EC� AS PAR i t�F i Hf� APP�IC�76�i�. <br /> ClTY U�E: Date Fee f'aid: Amount: Receipt No.: <br /> Date Counci; Approved: License No.: <br /> � _.,__ ...�� <br />