Laserfiche WebLink
<br />Incorporation Date: <br /> <br />\\ \0 \ <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 />Sociai Security Number: <br /> <br />ALL APPLICANTS: <br /> <br />" <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 descnoe their interest in detail <br />below. <br /> <br />~(.:)cr:) rv\"<:"~L ~ <br /> <br />to, <br /> <br />Addresses: ~Ilc bfl, l A iW \)i2... ~ <br /> <br />l.srwv-..I/Lv , L u;: . <br /> <br />Assumed or Trade Names, if any: <br /> <br />~ <br /> <br />Business Telephone Number: h~\ -\..('2..(, ~~ Home Telephone Number: c';'S \ -11c 1.. ~~S.s 2- <br /> <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes &4 No <br /> <br />_nse, date, county and stated of conviction: <br /> <br />rJjlt- <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 />Federal Tax Identification Number: <br /> <br />5tO~~S. <br />4'1 - )1...'01.. '\.:os. \ <br /> <br />Minnesota Tax Identification Number: <br /> <br />Signature: <br /> <br /> <br />cation Number is not required, please explain on the reverse side. <br />Position (Office, Partner, etc.): ~~ <br />Date: lD h..:-; )0-:7 <br /> <br />Print Name: <br />