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<br />Incorporation Date: <br /> <br />fE,:'?J II; rJ) /k20/; <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 describe their interest in detail <br />below. <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: 6. {, - 6 s. J - 77 9t Home Telephone Number: & S I ~ 'I a 2- 7 JIJ / <br />Has any person named in the application ever been convicted of a felony? D Yes ~ No <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 qua1ifications of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: ~:J. - 050.5;), <br /> <br />Federal Tax Identification Number: :) 0 - '1J~ 7<l.3~ <br /> <br />If a Minnesota Tax Ide . ca. on Number is not required, please explain on the reverse side. <br />Signature/ Position (Office, Partner, etc.): (Jf( /51121 N '1" <br />f <br /> <br /> <br />Print Name: "16t;(/AIlJ{ i .:f. >96tf' Date: J.,/J '/ah <br /> <br />4P <br />