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<br />Incorporation Date: d J /6, Jo06 <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION Of sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant'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 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 />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: -'9 ~ 1791 Home Telephone Number: ~7}' ') '}OJ <br />Has any person named in the application 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 manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: <l J. - Os 0 5 1 <br /> <br />Federal Tax Identification Number: do - i./J 'I) ~ Jg <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Signature: ~ Position (0Ilice, Partner. etc.): -11< /S JI]'~'Y <br />PrintName: '~AIMtI. ffijvli.S Date: JO'S .Jb <br />51ive · <br /> <br />13 <br />