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<br />.. <br /> <br />'iI <br /> <br />, Incorporation Date: <br />List of~rs: <br /> <br />List ofStockhol4ers: <br /> <br />. . <br />PERSONAL INFORMATION (if sole proprietor): <br />Applicant's Name:, ~ <br /> <br />Applicant's A~: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Nmnber: <br /> <br />Social SecurityNmnber: <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 ~ under the license for which this application is made and describe their interest in detail <br />below. <br /> <br />M~t:/1a1 r~~-I'tSw~ <br /> <br />Addresses: t{(f:J- [~'l Aw.. tf4U~ .IAIIJ .N"'12.-f' <br /> <br />Asswned or Trade Names, if any: <br /> <br />f9~/-..fU-667f <br />Business Telephone Nmnber: <br /> <br />6~/- 530 -<< 00 <br />Home Telephone Nmnber: <br /> <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 qualifications of a <br />licensee and that the manager will D.ot violate any city or state laws. . <br />Minnesota Tax Identification Number: 6' f'1lJ 1~( <br />Federal Tax Identification Number: 83 - 0 b 8' 7'16 g <br /> <br />. If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Signature:~1f vJ.-- Position (Office, Partner, etc.): ~"'~" <br />. PrintName:/11~Gfwt,f., fdtllf1tV Date: 10'" J/-tJI.{ <br />