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<br />. ~ <br /> <br /> <br /> <br />'1 <br /> <br />CERTIFICATE OF COMPLIANCE <br />DEPART:MENT OF REVENUE' <br /> <br />I <br /> <br />, , <br />Pmsuant to Minnesota St.a:tute 270.72 Tax 'Clearance; Isswmce of Licenses,: the licensing <br />authority is reqoiredto provide to the Minnesota Commi~oner of Revenue your Minnesota <br />Business Tax Identification Number and the social seCuritv number of ea.eh license <br />aDuHcant (uerson monm2' the aouHcation). <br /> <br />Under the Mfunesota Government Data. Practices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use of this .uauulIi:atlon: <br /> <br />1. This informa1ion may be ~ed to deny the ~, renewal, ortlaosfbr of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or interest; , <br /> <br />2. Upon receiv.ing this information, the license authority will supply it only to the <br />Minnesota Department of Rcveme. However, under the FedeJ:al Jl"l'l"~ of <br />Info.unation Agreement, the Department of Revem1e may supply' this <br />information to the 'fntP.mal Rcveme Semce; <br /> <br />3. Failure to supply this information may j~ or delay the ~g of <br />your license issuance. <br /> <br />Please supply the joliowtng irif01'1(lation and retuni along with your application: <br /> <br />lYPH OF UCBNSBBHlNG APPLIED FORORRBNBWIID: ~ <br /> <br />PERSONAL INFORMATION: <br /> <br />~licant's Name: <br />Applicant's Address: <br /> <br />e.JJII- BI/,.C,H,l.p!l <br /> <br />I~ 87 /f!4U AJ.b TA/ <br /> <br />CslJr~ V/t-./,.e . m)J .15"9$8" <br />[City]" [State] [Zip] <br /> <br />Soclal SeCurIty Number: _ <br /> <br />:"BUSlNESS INFORMATION: <br /> <br />Business Name: <br /> <br />c'6P T GL AI/JA! r <br />/ ~t:I / AlII/AI S7", <br /> <br />Business Address: <br /> <br />D6NT6tv/u,.E' {r/)./ ~.:JK <br />[City] [State] [Zip]. <br /> <br />Minnesota Tax ldentiftCation Number: '}CJ' /750- I <br /> <br />Federal Tax ldentiflcation Number: dO-II L/ IS.5~ <br /> <br />If a Minnesota Tax Identtflcation Number is not required. please erplain on the reverse side. <br /> <br />11;'10'1 . ~'~~ <br />Date Sigoatore and Position (Officer, Owner. Partner) <br />