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m <itol •. I ‘ • <br />. As the person executing 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 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 iiability for damage which <br />may result from furnishing the information requested. <br />I. 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 />PPLICATIQK. <br />iigna^i^W (Title) <br />\ , <br />notary stamp) <br />Subscribed and sworn to before me this <br />^^^day of K . 20 <br />......... <br />SEE ATTACHMENT FOR ADOmONAL DOCUMENTS REQUIRED AS PART OF THIS APPLICATION. <br />CITYUS6: Date Fee Paid; ;(/14 /C i:- Amount:Receipt No.: w /' <br />• <br />Data Council Aooroved; <br />• <br />License No.: <br />« <br />*f *