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<br />Incorporation Date: <br />List of Directors: <br /> <br />~d <br />fJeUi. <br /> <br />, <br /> <br />Ifit <br />/Il ~ /l.J -ptJ JAJ <br /> <br />'\ <br />. '" ,_. f: <br /> <br />. ;J!JeVL ../J1t1)A) TA/N <br /> <br />, ~ . <br /> <br />'. List of Stockholders: <br /> <br />'. . . . <br />PERSONAL INFORMATION (lfso1e proprietor): <br /> <br />=:::: p:};~ PJ:~ q' . <br />~. ~..~ /I!/Ll. SS03~ <br />. . [City] [SUIte]. [Zip] <br />HomeTelephoneNmnber:II~ ~)I.- U3-' Og~ 'C: bSi ;)6/-;)1<1; <br /> <br />Socia1 Secmity Number: <br /> <br />ALL APPLICANTS: <br /> <br />List all persons or entities with either a direct or indirect interest in the awJ.cant or the apPlicant's business <br />to be conducted 1.mder the license for which this application is made and desctibe then' interest in detail <br />below. <br /> <br />4 <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Nmnber: Home TelephoneNU1Ilber: <br />Has an;y p<IllODllllIlIlld in the applicalion ewr been - of. fOIooy'I D Yes f No <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />Applicant agrees that any JIl8I18F1' 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 />Minnesota Tax Identification Nmnber: .3 6 (, :J... ~ J 9' <br />Federal Tax Identification Number: LJ I J '- ~ '"- )( t. '7.r <br /> <br />~.~~~~plesseexpain...the.......aido. /J . <br />Signature: ~~_ Position (Office, Partner, etc.): r ~,. <br />Print Name: {?4.UL fHf)N7~J~: / /) ... ~'~--Or . <br />