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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 inforrnation 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 resuft 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 appiication. 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 ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br /> APPLICATION. <br /> r,, <br /> i^. �. .. c <br /> k / j,, �,� ' <br /> `_L_-j��.r V 6�� L' jY:•�_ti�/�,d�'t'G!/Y l��`✓C. ��G.-?�r.��'•�.� . <br /> (Signa�ure) � (Title) <br /> L- <br /> Subscribed and sworn to before me this <br /> (notary stamp) �� � , �. <br /> day of ����'���;� , 20 �%�: <br /> JcUti1FER ST�IN <br /> �� NOTARY PUBLIC-MINNESOTA -. <br /> ` ;�,,.:+' My Canmission Enpues Jan.39,2010 '' ` <br /> �'�-"'" - j� �; �� �"�-- <br /> (No ary �'"�b ic/City lerk) <br /> � <br /> �E� AT�'ACHIV�E�9� F�� �C�1�6T6C76�AL ���l�iViEi��� ��C�LI1���7 ��a �I��tB �.?0= 9 Fi�S A�PLI�AI iCD�. <br /> ���� ��l�L: Date Fee Paid: a 1 �? '��C � Amount; ?'� �' - �' � Receipt No.. �,i- ��—%� l <br /> IDate Council Approved: License No.: <br />