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<br />/.. <br /> <br />/' <br /> <br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />. Pursuant toMbmesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required. u.>"Provide to the Minnesota Commissioner of Revenue your Minnesota, Business Tax <br />Identification Number and social security number of each license. applicant. . . <br /> <br />. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use oftJrls information: . <br /> <br />1. This information may be used to deny the issuance, renewal or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinqueirt <br />taxeS, penalties or b1terest; <br />2. Upon receiving this information, the licensing authority will supply it only to the . <br />Minne.sota Department of Revenue. . However, under the Federal Exchange of <br />Information Agreement the Department of Revenue may supply.this information <br />to the Jnternal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal awlicai:ion. <br /> <br />Please supply the following information and retmn along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />. LICENSE TYPE: ()"/~JI' S'8t1! S.Z/SAJI'U'l NEW [] RENEWAL l><l <br /> <br />LICENSJNG AUTHORITY: City ofC'..entervt11e <br /> <br />LICENSE RENEWAL DAm: ;{;",,/ . / b 5 <br />, <br /> <br />BUSINESS INFORMATION: <br />Business Name: JCI., l!y ~ ~r,J~t< I he. <br />Business Address: ?Pf8'- (f,/nrt//tk ,;~ <br />C~ 11,.1/; II! . ;11,,; <br />. <br />[City] [State] <br />Business T~lephone Number: ~1 / - &, S;3 .. /) P 9'/ <br /> <br />55'~J 8' <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social ~ number): <br />Full Name: W,I/I/"'~ 13ISl,"k '. <br /> <br />Title: I~,.$. , <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full ~ame: <br /> <br />Title: <br /> <br />Social Security Number: . <br /> <br />IF A CORPORATION: <br />Corporation Name: li,ll,! $ .IC~/'''rt; f~c, dba it, fly ~ }6;rltlt". <br />Business Address: ?#f8'.. a~h"'tI//I~ IV. Ce~/f;'II,Jlc <br /> <br />. <br />