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City of <br /> Pequot <br /> Lakes` <br /> INFORMED CONSENT FORM <br /> City of Pequot Lakes <br /> 4638 County Road 11 <br /> Pequot Lakes, MN 56472 <br /> 218-568-5222 <br /> Contact Person: Sandy Peine, City Clerk <br /> Date: <br /> The following named individual has made application for a License with this agency. <br /> Last Name of Applicant(please print): <br /> First Name of Applicant(please print): <br /> Middle(Full)(please print): <br /> Maiden,Alias or Former(please print): <br /> Date of Birth: Sex(M or F): <br /> (Month/Day/Year) <br /> Applicant's Social Security#: <br /> Driver's License Number: State Issued: <br /> I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record <br /> information to the City of Pequot Lakes for the purpose of acquiring a license with this agency for <br /> (license type)pursuant to Minnesota State Statute 299C.72. <br /> Signature of Applicant Date <br /> Applicant's Phone Number: <br />