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<br />Incorporation Date: <br /> <br />~~/!Ju4 <br /> <br />~i:L(J /I1C/~~ <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 Security 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 /> <br />beWw. ~ 1 <br /> <br />to_ <br /> <br />/1/tJlU7/J- J /lJ <br /> <br />05/0 (~;.~L6 4 <br />/~ &A /If/lJ L~\O]Y <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number:b5?-~) t . J. ~ S J:, Home Telephone Number: &5/- t <{3- 0 gSJ <br />Has any penon named m!be application ever been convicted ofa felony? D Yos 'f.. No <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: ") (, ~~;2 ;LI,f <br /> <br />Federal Tax Identification Number: 4 ) - /3' .sr ~ '1 r <br /> <br />~ a Minne~ota den0.catiOn~Nllmhe ~ not ~~quired, please explain on the reverse side. <br /> <br />SIgnature: ~~~ ~. POSItion (Office, Partner, etc.): ~~ <br />, <br />Print Name: ~q j., /J1 ofi}7R//L/ Date: ,II () -/7- OJ <br />