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2003-11-12 CC Packet
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2003-11-12 CC Packet
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<br />TAXCLEARANCE~ORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />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 />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Depar1ment of Revenue. However, under the Federal Exchange of <br />Information Agreement the Department of Revenue may supply this information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: <br /> <br />L J QlIO,~ <br /> <br />NEW [ ] <br /> <br />RENEWAL V4 <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />LICENSE RENEWAL DATE: <br /> <br />I ,.../-&'1 <br />8 <br /> <br />Business Telephone Number: <br /> <br />BUSINESS INFORMATION: <br />;?7fJU/U 7/7-);0 f~ \~- /)6 A- <br />70 g~ Ced~~ e/ <br />~~ //f/U cD~63cY <br />[City] '[State] [Zip] <br />rP( <)/ - Lj ~:11o '" :;lq~ ~ <br />(full DlUIJ<;~ty nnmber): <br />~ .~~~ fA 1;1.1 <br />h~- <br /> <br />~~ <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />List of Officers or <br /> <br />Full Name: <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: /I};Jd7IJ-rAJfV r;~~ .#V14ba ~-:;. ~ <br />Business Address: 17 {) ~ 1 ~~J fi/ ~~jjJ.Aj <br />~03eY <br />
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