Consent for the release of information

Each owner and/or manager of the business selling liquor needs to fill out this form.

This consent is for the relase of information in accordance with MSA 13.05, subd. 4(d).

I authorize the Ramsey County Sheriff’s Office to release criminal history data, as defined by Minnesota Statute 13.87, subd. 1 and driver’s license and traffic record data to the Deputy Clerk for the City of Shoreview. I understand that some of this data may be classified as private data under Minnesota statutes and I hereby give my informed consent to the release of that private data by the Ramsey County Sheriff’s Office to the deputy cerk for the City of Shoreview. This consent for the release of data is for the purpose of obtaining a permit or license with the City of Shoreview. This information cannot be used for any other purposes. This authorization may be revoked in writing by me at any time and in no event will it be valid for more than one year from the date below.

Yes

Other names (maiden name, previous marriages, previous aliases)

Sex

Driver's license number and issuing state

By signing this application, I:

Swear that all statements by me on this form are true and complete to the best of my knowledge
Understand that false statements or omissions shall be sufficient cause for rejecting my license
Authorize the City of Shoreview to use this information to determine my suitability for obtaining a license.

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First Name

Last Name

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By signing this application, I agree to the above conditions.