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<br />".. . .'" co <br /> <br />List of Directors: <br /> <br />7// /d~ <br />~ of Jf3wlX ~'- <br />?~l.~~ <br />~- ' <br /> <br />.. lnoorpomtionDate: <br />.. <br /> <br />List of Stock:holders: <br /> <br />'~:OSONAL INFORMATION (1.f sole proprietor): <br />AppJicaot's ~ <br />AppJicanf.s Address: <br /> <br />/ <br />./ <br /> <br />[atyl [State] <br />HomeTe1q>>ho.neNmnber: q S I 7~ ;2 / ~b <br /> <br />Sacia1 Sclcurit}r Nu:mber:: .- <br /> <br />[Zip] <br /> <br />ALL ~LICAlft'S: <br /> <br />~.. -:r. 'ol ~. ' ", <br />List aU persOns 01' entitieS with el1he..- a direct or iodirect hJteJest in tbe appliamtortbe appJicant"s ~ <br />to be conducted. under the license for which this application is made and desc.tibe their intereSt in del3il <br />below. . ..; <br />. . <br /> <br />eAJ."'~ ~, <br />./t1e7 /fI~ 'r~ <br /> <br />,. . <br /> <br />, ~~.Fn '8 <br />~ 'J ~ <br /> <br />~t/ &.- ~,/t/~ <br />, " <br /> <br />/H~~ <br />~ .. <br />.. . . /II#(~ <br />') ", <br /> <br />~ .~. <br />~'Or'nodoNaaloi,if~ . ' ,~ ~ <br />- y <br /> <br />~Te1ephone:Nunmer.I$'-~.- /fBtfo ~T~Number: /'6-/-: 71 ;;. ../~ <br /> <br />HasanypelS01l~inthe~1iatti~~beenconvictedofa:fetony.1:, D Yes l( No <br /> <br />Jfyes. ~forth the ~ ~: COUDty and stated ~ COIl'riction: <br /> <br />'/ <br />/', <br /> <br />. . <br /> <br />AppJiamt agrees tbat any maoager Cmployed m'the JiceJRd ptemises wilI':have an cpm'Hficatioos of a <br />licensee and that tbe manager wiD DOt vioJate any city or state laws: .. , . <br /> <br />Minnesota Tax:Td~catUmNmnber. ',' 7'0 17 S.5 I <br />Fedexal Tax ldentificationNomber: :l () - II t/ IS 5' ~ <br /> <br />If a Minnesota Tax TdP.ntificmiQJl Number is not requhed, please explain on the reveISC side. <br /> <br />Signatuie: <br />PrintName: <br /> <br />Position (Office, PaItner. etc.): <br />Date: <br />