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<br />I <br /> <br />CEKrD1CATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />I <br /> <br />I <br />~ <br /> <br />Pm:swmt to Mitinesota Statute 270.12 TaX Clea.nU1ce; Jssuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your MiDnesota <br />Business Tax Identification NUmber and. the social setoritv number of each Hcense <br />aDuHCaIIt (nerSon sioninl! the aD'OHcation). <br /> <br />Under the Minnesota Government Data Pmctices Act and the Fede.ral Privacy Act of 1974, we <br />are required to advise you of the followlng regarding the use oftbis iofor.manon: <br /> <br />1. This infonnation may be used to deny the issnatme, renewa.t, or 1:IaDsfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or interest; <br /> <br />2. Upon receiving this information, -the license authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal. EYl".Jun,ge of <br />Information Agreement, the Departm.ent of Revenue may supply this <br />information to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the pl"OCCS$i1l8,'Of . <br />your license issuance. <br /> <br />Please supply the following iriformtition and return along with your application: <br />1YPE OF LICENSE BEING APPLIED FOR OR RENEWED: ~A~ <br /> <br />PERSONAL INFORMATION: <br /> <br />Appltcant's Address: <br /> <br />~no S~ <br />. (o'rl \0 t (l,\AA <br />e.~I2>>~\\t ~ <br />[City] rStatel <br /> <br />,. <br />nfl,\ v~ <br />5So~ <br />fZjpl <br /> <br />Applicant's Name: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />BustnessName: "0 'S\c.~ ;~,. J>M Corua~~ sS' <br /> <br />Business Address: \~t) M~ S~... <br />~\'f(l.V~ \LQ lV\.tJ SS03 B <br />. [City] [State] [Zip] <br /> <br />Minnesota Tax Identification Number: S 10 '5ltJ () S <br /> <br />Federal Tax Identification Number: Ifl- an..1 (." S , <br /> <br />If a Minnesota Tax Identification Number 'Is not required, please explain on the reverse side. <br /> <br />.~~ .L <br />\ o. ~ ttl...::t" <br />. . (0J1icer, OwneI;Partner) <br /> <br />