Laserfiche WebLink
<br />Incorporation Date: <br /> <br />List of Directors: <br /> <br />List of Stockholders: <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 conducted under the license for which this application is made and descnbe their interest in detail <br />below. <br /> <br />--1!{lP4i1ltf ::h/VIf5 J16~ - .J$[<;JIJ{~~.- tJw.vf4 <br /> <br />Addresses: .51~S /5) 11 S7. d! J t1iltJt~)}/l?/I/. Sff)l~ <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: t5/~ '1:Jb .'6A 7'( <br /> <br />Home Telephone Number: ~JI'" ~} 7 J 7 Jv J <br />D Yes ~ No <br /> <br />Has any person named in the application ever been convicted of a felony? <br />~e, 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: . ~ 7 J 71'1 J <br /> <br />Federal Tax Identification Number: Lj/ -170 77~3 <br /> <br />If a Minnesota Tax Iden' ation Number is not required, please explain on the reverse side. <br />Signature' Position (Office, Partner, etc.): fJtPf r ....j r,4; 1'" <br />Print Name: ~;rll4.tvf~ ::(.$16[( <br />, <br /> <br /> <br />Date: <br /> <br />)f)-7-0J <br />, <br />