11-28-2005 Council Packet - Laserfiche WebLink

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/f.-' '■-> ^ vV’'4‘“V‘ 4 * . A I. As ths porson executing this application for this license, I acknowledge that an investigation will be oondudad for use in determining my qualifications. I hereby expressly authorize release of any and all Information which any organization, company or person may have. Including information of a confidential or privileged nature. I hereby release the City and any organization, company or person ^ furnishing information to the City, as expressly authorized above, from any liability for damage which may result from furnishing the information requested. ). The Information requested on this form will be used by the Qty of Orono In the issuance of your license or processing of your renewal application. The information that you supply on this form will become public Inferrrwtlon when received by the City of Orono. Under Minnesota law (M.S. 270.72), the City may be required to provide the business tax identification number and social security number of each applicant to the Minnesota Commissioner of Revenue. MY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WILL RESULT IN DENIAL OF THE PPLICATION. nature) AA C‘o«.r‘3<* (Titie) ^ notary stamp) Subscribed and sworn to before me this day of ..20. (Notary Public/City Clerk) SEE ATTACHMENT FOR ADDITIONAL DOCUMENTS REOUIRED AS FART OF THIS APPLICATION. CITY USE: Date Fee Paid: nl/7/C> _ Amount: ^ A Date Council Approved Receipt No.: J»t***/'* ^ ♦ License No.: \ ■ i ■ I . 1 ■: i < ■