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2003-11-12 CC Packet
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2003-11-12 CC Packet
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<br />CERTIFICATE OF COMPLIANCE <br />. DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Numb~r and the social securitv number of each license <br />auulicant (uerson si!min2 the auulication). <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use of this information: <br /> <br />1. This information may be used to deny the issuance, renewal, or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or interest; <br /> <br />2. Upon receiving this information, the license authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement, the Department of Revenue may supply this <br />information to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br />.: . <br />TYPE OF UCENSE BEING APPLIED FOR OR RENEWED: ~ <6?1 <br /> <br />PERSONAL INFORMATION: ~ <br /> <br />Applicant's Name: .t:;dt/l._ /l! f) /J)-rA );) <br /> <br />tb C;JO ~ .R(J <br />J.. J;tJO 1Aj{~s <br />[City] <br /> <br />Applicant's Address: <br /> <br />/fI;U <br />[State] <br /> <br />~t) if <br />[Zip] <br /> <br />Social Security Number: <br /> <br /> <br /> <br />SSOO'ORMATION: <br /> <br />""'~~J"" <br /> <br />Business Name: <br /> <br />;J2~.&c;. ~A,~ ~ .LJO'.J ~~ <br />IV 0;2 &./e~~4 /dIJ .J.?,., <br />&~~ /11Ll . ~fb~r <br /> <br />- <br />[City] [State] [Zip] <br />3' ~rl ~/t <br />'-! 1- I r-.~I t, 71 <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />/12 ~ /7--03 <br />Date <br /> <br /> <br />If a Minnesota Tax Identification Number is not required, pl <br /> <br />Signatme and Position (Officer, Owner, Partner) <br />
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