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<br />Incorporation Date: <br /> <br />IW \ <br /> <br />List of Directors: ~ '. _lll ~ <br /> <br />~C$'i..lt <br /> <br />List of Stockholders: <br /> <br />We L\ Ll:......... <br /> <br />~( ~~(, <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Secmity Number: <br /> <br />ALL APPLICANTS: <br /> <br />List all persons or entities with either a direct or indirect interest in the applicant or the applicant's business <br />to be con.ducted under the license for which this application is made and descnoe their interest in detail <br />below. <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: <br /> <br />Home Telephone Number: <br /> <br />Has any person named in the application ever been convicted of a felony? D Yes ~ No <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />Applicant agrees that any manager employed in the licensed premises will have all qualifications of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: J S / 91 /) 0 <br /> <br />Federal Tax Identification Number: Iff - Ijl ~.l CJ 'I <br /> <br />If 'M~T~~ ~; is not ~ please explam on the....". side. <br />s~~ Position (Office, Partner, ""'.J, 13.u., <br />Print Name: kJ/t~_nv 8'5Se Date: IIJ,hAj~~ <br />