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As the person executing this application for this license. I acknowledge that an lnvestigat«on will be <br />conducted for use In determining my qualifications. I hereby expressly authorize releas'j of any and all <br />Information which any organization, company or person may have, Including information of a <br />confidential or prMIe^ nature. I hereby release the City and any organization, cocnp£ ny or person <br />furnishing information to the City, as expressly authorized above, from any liability for damage which <br />may result from furrrishing the information requested. <br />) 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 />MY falsification of answers to the above questions wiu result in d enial of the <br />PPLICATION, <br />. • V <br />Signature)(Title) <br />notary stamp) <br />Subscribed and sworn to before me this <br />day of 20fj& . <br />(Nma(Notary Publio’City Clerk) <br />SEE ATTACHMENT FOR ADOmONAL DOCUMENTS REQUIRED AS PART OF THIS APPLICATION <br />CITY USE: Data Fee Paid: Amount:__iiC;il_Li <br />Date Council Aoorovad: <br />Receipt No.: <br />License No.: <br />Ii^aiiainaie ii