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As ths psrson sxocuting 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 infbrrfiation 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 />e'' <br />1 <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 />NY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br />PPLICATIQN. <br />ft- <br />Signature)(Title) <br />v' <br />notary stamp) <br />CHRISTOPHER JOHN SPC6LER <br />MMiyPuMe-iannMOla <br />CoHwilMlow Mm Jw>. 31.2010 <br />Subscribed and sworn to before me this <br />^ ^ day of 20^^". <br />i <br />(r^otary R66llc/Clty Clerk) <br />sxBa <br />SEE ATTACHMENT FOR ADDITIONAL DOCUMENTS REQUIRED AS PART OF THIS APPLICATION. <br />% <br />1^.A <br />CITY USE: Date Fee PaidAmount ‘ r t*Receipt No.: 6 V- ^ <br />m:Date Council Approved License No.; <br />L <br />‘ ! <br />. • • •• <br />• 1 <br />• .V* <br />iA