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<br />Incorporation Date: ~ - J, '; - ~ '1 <br />List of Directors: Jt;U)/7erf4 F {//fAJ-allJ2 r.JOt:LiC <br />J (.0 Je h1 f/'/hJ ()e ~ t3..riJ:; C <br />List of Stockholders: S ~ <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 />JtJOfJ+J~ <br />. <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: <br /> <br />Home Telephone Number: <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes 1}a No <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />r <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 />Federal Tax Identification Number: <br /> <br />If'~aia notrequhed, please explain on the rev.... side. <br />Signature. - Position (Office, Partner, etc.): ~P-S .. ~ <br />Print Name: -k.e.nnl!TJ..J Date: 5-/3-(;""'3 <br />F tt/Ih.; lJ.f!.r 11ee.!( <br />