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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 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 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 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 receiving 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 SeIVice. <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: <br /> <br />L / {V tJ () (( <br /> <br />NEW [ ] <br /> <br />RENEW AI.. [Xl <br /> <br />LICENSING AUTIIORITY: <br /> <br />City of Centerville <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br />Business Name: ell; S'~G (! Y 5 ~ 2 Z/T .-;- <br />Business Address: '70 9s:- ?-cJ '7J-J J9vC <br />~:/7Tt"fi/1 LLr m rJ <br />[City] [State] <br /> <br />R'l? <br />'-- " <br /> <br />:5:C:;-OS.~ <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: ,;fP/7/J~J}d FR//4rYS f//lYO-P/l8eE/C' <br />"" <br />Title: ~e.f.I/:::k4"'- <br />Full Name: JUL / ~ /IJ /7 /? I P:: <br />Title: .)eC/t ff f7't*T1 <br />Full Name: <br /> <br />Social Security Number: <br />!/8/V;:)t' /f g~~ /t::.: <br /> <br /> <br />Social Security Number: <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: {;.h)t r; U (5 t 2-111 I II l dba <br /> <br />WI S ~ (, t.I V 5 <br /> <br />(j-z zrr <br />, <br /> <br />Business Address: <br /> <br />~ <br />