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<br />... <br /> <br />TAX CLEARANCE. INFORMATION <br /> <br />. <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 ConuniSsioner 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' inf~on:' . <br />. . <br /> <br />1. This information may be used to deny the issuance, renewal or transfer of your <br />licei1se in the. event you owe the Minnesota Deparbnent 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 Deparbnent of Revenue. However, under the Federal Exchange of <br />Information A~~ the Departm.eirt ofRevenue 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 OFREVENlJE. . <br />IJCENSE TYPE: ",,,,Il. / --n D4e€e? NEW [] RENEWAL [.v(" <br /> <br />IJCENSING AUTIIORITY: <br /> <br />City of Centerville <br /> <br />IJCENSE RENEWAL DATE: I'" /-6~ <br /> <br />BUSINESS INFORMATION: <br />ausinessName: Cen~tlJlk .lJ1t1~/L~ <br />BusinessA~: 7~fJ ~ 'PI .k-. clw1? <br />~~etl.IIIUI" A,fAJ. <br />[City] [State] <br />Bu,siness Telq>hone Number: 6'71 - '{71 -6.6 "7Y <br /> <br />sn; -S K' <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: A4e.tltPe,/ '11td/ll1P5' WIll f ffltJY <br /> <br />Title: OW I)l,Y Social Security Nmnber: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Nmnber: <br /> <br />Full:Name: <br /> <br />Title: <br /> <br />Social Security Nmnber: <br /> <br />Full Name: <br /> <br />Ti,tle: <br /> <br />Social Security Nmnber: <br /> <br />.IF A CORPORATION: <br />Corporation Name: b f14W J'i?,. <br />Business Address: 7 tJf.; 2CJ p, <br /> <br />dba {;'4Itr-//,lIe tfl/i1~5 <br />Ate dW'/1" {'~~7~ tVtAl SSo ~R <br />