Xxxxxxxxx Warning. The Department of Public Safety (“DPS”) collects the information on this form for identification purposes, to enroll you in the Minnesota Ignition Interlock Program ("Program"), and as required by Minnesota Statutes, section 171.306(3)(a), which states "[a] person who seeks to participate in the program shall sign a written acknowledgement that the person has received, reviewed and agreed to abide by the program guidelines." You are not legally required to complete this form. You can refuse, however, DPS cannot enroll you in the Ignition Interlock Device program. Program participants are subject to the terms and sanctions set forth on this form and in the Program Guidelines. Driving while intoxicated, and violations, may result in criminal prosecution, probations violations and loss of driving privileges for Ignition Program enrollees as well as individuals not enrolled in the Program. For Program enrollees, violations of the conditions outlined in the Program Guidelines may result in sanctions including, but not limited to, an extension of time on the program and/or non-credit for the revocation time spent using the ignition interlock device. DPS will not share this form with other entities; however, through the program, DPS collects driver's information that may be released to the following: state and federal enforcement agencies; licensing boards and agencies; state and federal courts; law enforcement agencies and prosecutorial authorities; persons and entities named pursuant to a court order; and any other person or entity authorized by state or federal law. DPS will share driver's information with the U.S. Security Administration, U.S. Selective Service System, U.S. Department of Labor, the Minnesota Attorney General's Office and Secretary of State's Office, and the Minnesota Departments of Human Services, Revenue, Commerce, Natural Resources, and Veterans Affairs.
Xxxxxxxxx Warning. Addendum A: Xxxxxxxxx Warning on Page 10 of this MOU must be sent to and on file with the DVS Supervisor in your area for all Knowledge Test Proctors, the Administrator and for all test takers.
Xxxxxxxxx Warning. In accordance with the Minnesota Government Data Practices Act, we are required to inform you of your rights as they pertain to the private information we collect from you. The information we collect from you is classified by law as either public (anyone can see it), private (the public is not given access, but you are), or confidential (even you cannot see the information).
Xxxxxxxxx Warning. Private or confidential data is requested on this application in accordance with MN Statute 13.04 Subd.2. for official purposes, such as validating your identification, contacting you for official city business, collection of delinquent balances, consideration of a payment plan, etc. Your information will only be accessible by City of Xxxxxx staff and those otherwise allowed by Minnesota Statutes Chapter 13. You are not legally required to provide this data and may refuse to do so but failure to provide the requested information may result in refusal of utility service, or inability to participate in a payment plan. Applicant’s Name(s) Owner: Yes or No Renter: Yes or No Service Address City State Zip Billing Address City State Zip Phone # (home) (work) (cell) Email address Applicant’s Signature Date Joint Applicant’s Signature Date If Renter, list Owner’s Name Owner’s Address City State Zip Owner’s Phone # (home) (work) (other) For $3 or less each month, the energy you consume can come from eco-friendly, renewable resources when you participate in Clean Energy Choice. o For $3 or less each month, the energy you consume can come from eco-friendly, renewable resources when you participate in Clean Energy Choice. o For an additional $3/month, I'd like 100% renewable energy. o For an additional $2/month, I'd like 75% renewable energy. o For an additional $1/month, I'd like 50% renewable energy.
o I do not want to participate in Clean Energy Choice (renewable energy) at this address.
