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2003-11-12 CC Packet
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2003-11-12 CC Packet
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<br />TAX CLEARANCE INFORMATION <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 Department 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: 77J hA-~(!O <br />f <br /> <br />NEW[] <br /> <br />RENEWAL ~ <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />lit/or! <br /> <br />f ( <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br /> <br />Y/zu m); ~ d J1}fJR)c~fs.7n<!. ~C/J- <br />I FIJI /Jl4/n si. <br />(!~mPlJ/J/~ 117M <br />[City] [S'tate] <br />Business Telephone Number: eft, S~) II $3 - 1./&9;Y <br /> <br />Business Name: <br /> <br />7fj/YI <br /> <br />Business Address: <br /> <br />5'~S~ <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />Full Name: w/i- I/;CI CC fJ 1/,' f <br />Title: IiJw /1 ~J"J /i~;<lt:n-j- <br /> <br />~ <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 />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: Jim iAllmh {:ill' rJJIJ_fs <br />Business Address: / / IJ ~ sf- / ? t1l sf.. <br />, <br /> <br />Lac <br />
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