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Criminal History Check Form <br /> Page 2 <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 employment with this agency as <br /> (job position)pursuant to Minnesota State Statute 299C.72. <br /> Signature of Applicant Date <br /> Applicant's Phone Number: <br /> Date: <br /> Signature of Potential Employer <br />