2023-03-14 P & Z Packet - Laserfiche WebLink

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Form #2 License Applicant Information Under Minnesota Law (M.S. 270C.03) the agency issuing you this license is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act, we must advise you: •This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue, or any other Department of Revenue in the United States, delinquent taxes, penalties or interest. •The licensing agency will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service. •Failing to supply this information may jeopardize or delay the issuance of your license or processing your renewal application. Please print or type in the following information and return along with your application. Applicant Personal Information: First Name: Middle Name: Last Name: Email Address: Street: Address of City: Residence: State:Zip: Driver's License # State of Issue: Social Security # Business Information: Complete Legal Business Name: Doing Business As Name: Store Phone #: Business Street: Address in City:Lexington Lexington State:MNZip: 55014 Minnesota Tax ID #Federal Tax ID # If Minnesota Tax ID # is not required, please explain: ______________________________________________________________________________ Date Signature Title