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TENNESSEN WARNING <br />Elk APPLICATION FOR BUSINESS LICENSE <br />River <br />In connection with your request for a license, the City of Elk River has asked that you provide <br />information about yourself, which is classified as either private or confidential by the Minnesota <br />Government Data Practices Act (M.S.A. 13.04). Accordingly, the City is required to inform you <br />of the following: <br />1. The private or confidential information requested includes, but may not necessarily be <br />limited to, the following: Your social security number or Minnesota business identification number. <br />2. The purpose and intended use of the information requested is: To comply with Minnesota <br />Statutes, Section 270.72. <br />3. You are required to supply the requested information. <br />4. The known consequences of supplying the requested information is as follows: Loss or <br />denial of the requested license ifyou owe the State of Minnesota delinquent taxes, penalties or interest. <br />5. The known consequences of refusing to supply the requested information is: Your request <br />for a license cannot be processed. <br />6. The following persons and entities are authorized by law to receive the information if <br />provided: State of Minnesota - Department of Revenue and othergovernment agencies as provided by <br />law. <br />Tho undersigned, by signing this notice, acknowledges that he/she has read and <br />understands the contents of this notice. <br />Z 22 f <br />Date <br />Cli.�g kid Wil <br />Signature of Applicant <br />