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<br />Incorporation Date: <br />List of Directors: <br /> <br />/99~ <br />~J')~e.1VI E-VA~/)~tJ~/<- <br /> <br />ListofStockho1deJ:s: -.-}<MIl.e 17f~f' VPnJ oJiP.,"BJi/L\l <br />JUt..I~ m fJ/t,J/J..ef2a~ <br /> <br />. . <br />PEBSONAL INJ'OR.MATION (If sole proprietor): <br />App1ic:aDt's Name: <br />Applic:ant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br />Social Secorl1y Number: <br />ALLAPPUCANTS: <br /> <br />List an peISODS or entities with either a ctirect or indirect interest in the applic:ant or the app1ic:ant's bnmness <br />to be conducted under the liceDse for which this appli<:ation is made and descn'be their interest in detail <br />below. <br /> <br />. ~/lJ)Jlr <br /> <br />Addresses: <br /> <br />Assumed or Tmde Names, if any: <br /> <br />Business Telephone Number: Home Telephone Number: <br />Has any personmunedin the appli<:ation ever been convicted of a fe1ony? 0 Yes 9J{ No <br />Jfyes. set forth the offense, date, c:ounty and stated of conviction: <br />I <br /> <br />Applic:ant agrees that any Dl8II8geI" employed in the liceDSed premises will bave an qualifications of a <br />liceDsee and that the manager will not violate any city or state Jaws. <br />MinnesotaTaxl~Number: '-Is 0:2, q 7 0 <br />Federal Tax Identification Number: t..j I ~ I <; ~ 0 7:1 Y <br /> <br />Jfa~ ~_islllll~ pkasoczplaia..,1he_sidc. <br />Si8"81~ --"" Position (Office, Partner. etc.): ~~eg 1 D ~1"\tJ" . <br />PriDtName:'~ Date: J()- 25-0'-/ I <br />,- <br /> <br />VltrJOeR,eel<-.. <br />