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fT <br />•I <br />>‘3 <br />ir <br />? A m. <br />I»•i <br />I ^ <br />). At thi person executing this epplication 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 />oonfidehtial or privileged nature. I hereby release the City and any organization, company or person <br />furnishing lnfom»tion to the CHy, as expressly authorized above, from any liability for damage which <br />may result from furnishing the information requested. <br />D. The information requested on tills 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 QRANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br />Signature)(Title) <br />Subscribed and sworn to before me this <br />H notary stan>p) <br />r! <br />Hi <br />VO day of W,\/~a j 20 <br />(tfotary Pu6!id/City <br />m <br />$f E ATTACHMENT FOR ADOfTIONAL DOCUMENTS REQUIREO AS PART OF THIS APPLICATION. <br />■%> <br />.. : <br />CITY USE: Date Fee Paid: f 11 fV/ <br />Date Council Approved <br />' • ^ t ' V ,t Amount: / J « • ^ ^Receipt No.: <br />License Na: <br />e ^ <br />.• • <br />.• . 1 <br />.1 <br />■« <br />. I