Laserfiche WebLink
<br />Incorporatimi Date:' /1 'II <br />List of Directors: . W , l ( ,~ 'B. s i ~ <br /> <br />.. <br /> <br />List of Stockholders: _W I \ l, t:c...-.. B J ~i /C <br /> <br />. . <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />AppliCant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zi? J <br /> <br />Home Telephone Number: <br /> <br />Socia18ecuritY Number: <br />ALL APPLICANTS: <br /> <br />List all persons or entities 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 />WII/,~ D/$t/~ <br /> <br />Addresses: I If 8 ff 0.. Xi./},.J -> I <br />AJf1do,)Y'! 141 #I 5' f )' :J ~ <br /> <br />Assumed or Trade Names, if any: <br /> <br />BusinessTelephoneNumber: (P11 "'~SJ- 'J?'/ HomeTelephoneNwnber: ~6J - '/,//f.../pl. i' <br />Has any person named in the application ever been convicted of a felony? 0 Yes Ii No <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />Applicant agrees 1hat any manager employed in the licensed premises will have all qualifications of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: 151 9 J ~ I) <br /> <br />Federal Tax Identification Number: if / ... I , /) f '$1) <; <br /> <br />Si <br /> <br /> <br />. on Nwnber is not required, please explain on the reverse side. <br />14' :> <br />Position (Office, Partner; etc.): <br />Date: {Jot. ':1/, ~ r <br />. <br /> <br />Ifa <br />