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TAX CLEARANCE INFORMATION . RECEIVED NOV 0 1 2004 '., " .. TO LICENSE APPLICANT: Pmsuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authori1;y is required to. provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required .to advise you of1:he following tegarding the use of this infQrJD.ation: . 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Depar1ment of Revenue delinquent tax~ penalties or interest; 2. Upon receiving this information, the licensing authority will !fIlPPly it only to the Minnesota Depar1mentof Revenue. However, under the Federal Exchange of . Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following information and ~ along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. UCllNSll1YPll: r . NEW [] RENEWAL?< LICENSING AUTIlO : . City ofCenterville LICENSE RENEWAL DATE: / -1- (;. ~ B~Address: ~)t) . J; Business Name: w [City] [State] Business Telephone Number: ~S 1- If ~ , ,. ;) rs. t [Zip] ~, ?-~/' ;;, /.. :l/Yf ,.. List of Ofticers or Partners (full name, title, and social security number): _ J Full Name:. /141/ ~ /ll 0/1) f/:///V Title: ~.f4L Social Security Number: _ Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: IF A CORPORATION- Corporation Name: 7>1 0l/Jt.11'A-1,v Business Address: 7 0 ~.. i ~~k ~4I ~.. .. =- ,/d1L 6:(Sb?~