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As the person executing this appiicatiori for this license. I acknowledge that an investigation will be <br />conducted fbr 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 from furnishing 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 />JY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE <br />aPLICATION. <br />(Title) <br />A-•h <br />lotary stamp) <br />Subscribed and sworn to before me this <br />^ day of . 20 of. <br />[■ <br />PETER W.XIHHSON <br />SSSSSiSSSS*// <br />(Nota?y-Pdblic/City Clerk) <br />SEE ATTACHMEHT FOR ADDITKHML DOCUMENTS REQUIRED AS PART OF THIS APPLICATION. <br />CITY USE; Date Fee Paid: UL l jo h Amount: Juw c (. h ^ ^ r Receipt No.: 7c o 5 <br />Date Council Approved:License No.; <br />A ? <br />•. • } <br />f . » s <br />•y;-. <br />• •