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CITY OF ELK RIVER <br />BACKGROUND INVESTIGATION CONSENT RELEASE <br />INFORMATION TO BE USED FOR BUSINESS LICENSE PROCESSING <br />Asa license applicant, I bereby give my consent far a personal background investigation, to include a criminal history check, to be used in <br />the determination of whether my application is to be approved. The results of sueb investigation sball be made public pursuant to <br />appropriate City Council approval or denial of the license application. I understand that I am under no legal obligation to consent to such <br />investigation, but that if I refuse to so consent, my application cannot be processed <br />I release the City of Elk River and the Elk River Polite Department, and any of its agents or employees, from any and all liability for its <br />receipt and use of information and records received pursuant to this consent. I further acknowledge that I have camfulymad this release, <br />fully understand its terms and legal significance, and execute it voluntarily. <br />Business Name: AplI S Type of License Applied for: dVi ed <br />Applicant: _�.YIU/I%'A! t un I <br />(First Name) (Full Middle Name) (Last Name) <br />Address: <br />roal -yn KiL Ma sSYn t3 <br />(City) I (State) (Zip) <br />Home Phone Business Phone: (713) 2f4 ( I � 1 -3 <br />Date of Birth: Place of Birth: % a1 H ' '11, <br />(City) (40) <br />Drivers License or State ID#: 05&447 � 23 State Issued: <br />T' A copy of the driver's license or state ID must be attached (front and back) <br />Physical: <br />Sex M Race kil Ht rI % it <br />wgt�14 V Eyes RU Hair�� <br />/ t'// <br />List All Aliases /Previous Last Names: f7 <br />List Complete Addresses of Any Prior Residence(s) in the Last 5 Years: (attach additional <br />Have you ever been convicted of a felony, gross misdemeanor, or misdemeanor? <br />❑ Yes P, No If yes, state jurisdiction, type of violation, and disposition: <br />Applicant Signature: 4/tom X l" Lt t-1 Date: `Z -2- / w 15 <br />These statements an true, correct, and are made with the knowledge that this information may be made public. False disclosures are <br />subject to pegug proceedings and forfeiture of the license application. <br />OFFICE USE ONLY <br />Background Check esti Approved LI Denied <br />Comments: ( ) , \ t i <br />Police Signature Date: <br />