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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 210.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Nmnber 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 of this 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 delinquent <br />taxes, penalties or interest; <br />2. Upon m:eiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement the Department of Revenue may supply this information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: OA)~iE <br /> <br />LICENSING AUTHORITY: Citv of Centerville <br /> <br />LICENSE RENEWAL DATE: 1-/-07 <br /> <br />BUSINESS INFORMATION: <br />I . <br />Business Name: SAbEl( ,5 1]41( oJ,v ,. 61;' JtL <br /> <br />Business Address: 709~ /t,lIijtJ~'/llJ'l (ll). <br /> <br />Udi 6/)';", t E JJJjl;'. <br />[City] [State] <br />Business Telephone Number: b r 1-/;5.3 . 1) 91 <br /> <br />NEW l ] <br /> <br />RENEWAL [Xl <br /> <br />SJ"i.Ur <br />[Zip) <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name:j;/! RI1y1){ l -SA (1! IS \,) A If; ;;;( <br />Title: /P j'5 ) {) 'J'/.I .-1" Social Security Number: <br />Full Name: <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: Social Security Number: <br /> <br />IF A CORPORATION: <br /> <br />Corporation Name: 5A.JiItWi( f)1 n'Jv~t:JofltJ. '1#(. dba $Ah~k'k &1?..1V~6R'L-t. <br />B. A~~- 7000 Cf;'1l ft.l?v'J /;t l jJo. A /\ <br />USlness uwess: v I J1. , 0'.,....,1 <br /> <br />12 <br />