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~ TAX CLEARANCE INFORMATION TO LICENSE APPLICANT: Pmsuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, 1he licensing authority is required'. to. . provide to 1he Minnesota 'Commissioner of Revenue your }4innesota Business Tax IdentifiCation Number.and social secmity number.of each license applicant. Pnder the Minnesota Government Data Practices Act and 1he Federal Privacy Act of 1974, we are required to advise you of the folloWing regardbJ.g the use oftbis ~on: . This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; . Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exc~ of Information Agreement the Department of Revenue may supply this information to the Internal Revenue service. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. ( Please supply the following information and retorn..along with your application to 1he agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF.REVENUE. . c.\\P~ 1. '2. 3. IJCBNSB TYPE: NEW[] RENEWAL [~ IJCBNSING A.unIORITY: IJCBNSB RENEWAL DATE: City of Centerville \ I vOoS BUSINESS INFORMATION: Business Name: ~i\~ ~p~S Business Address: \,Cb~' tV c:;rr- ~-~..,,, \e. [City] ('-\~ [State] '-\1...\, lo (, Of::> - ~~o 38 [Zip] Business. Telephone Number: to~\ List of Officers or Partners (full name, title, and social security number): Full Name: ~~ M\~ S,.,,~ Title: ~~~ Social SecmityNumber: . Full Name: Title: Social Secmity Number: Full Name: Title: Social Secmity Number: Full Name: Title: . Social Secmity Number: IF A CORPORATION: eorporationName:..:tD ~--" '!:-nC,.. - dba ~Q)IL ~)tI'~~S Business Address: ,~""o """,-J'nl'> b"T ..