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<br />List .ofDirectors: <br /> <br />l'2'\O\ <br />~OO ~~~ <br /> <br />~~\~ <br /> <br />~ <br /> <br />'Incorporation Date: <br /> <br />ListofStQckb.9IderS: <br /> <br />'. f\l A <br /> <br />. PERSONAL INFORMATION (if sole proprietor): <br />Applicant's Name: <br /> <br />~ppUcant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Security Number: <br />ALL APPLICANTS: <br /> <br />List ~ persons or ~es with either a direct or indirect interest in the applicant or the applicant's business <br />to be conducted under the license for which this application is made and describe their.interest in detail <br />below. <br /> <br />~QO N\~ ~.Ae- <br /> <br />Addresses: <br /> <br />U\1 \0 'e,,^,,~ <br /> <br />f' <br />~(l>.~ <br /> <br />.. <br /> <br />~J..J\\.A~ <br /> <br />Assumed or Trade Names, if any: <br /> <br />TD ~~'^ \ ~t'\c:.- <br /> <br />Business Telephone Number: l,6\ ~'U;, \ti~ Ofb Home Telephone Number: \0 ~, -Z l., 1. Ur 2- <br />Has any person named in the ~lication ever been convicted of a felony? 0 Yes ~ No <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />Applicant agrees that any manager employed in the licensed premises will have all qualifications of a <br />licensee and that the lIl8J1&ger will not violate any city or state laws. <br /> <br />Minnesota.Tax Identification Number: <br />. Federal Tax Identification Number: <br /> <br />S tCSloOC; <br /> <br />, <br />4.( -"U>"l.ll.oS 1 <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />SignaIore: ~~ PosiIion (Offico. _. etc.): ~IO.:t <br />. PrintName: ~~ Date: \\l (l 04 <br />