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<br />Incorporation Date: <br /> <br />/tft/3 <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 />below. <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: <br /> <br />Home Telephone Number: <br /> <br />/ <br />J No <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes <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: <br /> <br />'J ), 1,)- 1I'1;L <br />4/- 1Jf1/sst/ <br /> <br />Federal Tax Identification Number: <br /> <br />Ifa . <br /> <br /> <br />er is not required, please explain on the reverse side. <br /> <br />Position (Office, Partner, etc.): ,L /'et!91 5/l1i <br />/&b/J3 <br /> <br />Date: <br />