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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Oearance: 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 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: Off ~.IIl-i. NEW [] RENEWAL (X] <br /> <br />LICENSING AUlHORITY: City of Centerville <br />LICENSE RENEWAL DATE: I if /1 <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: Ce I) ft:no lit LUl vpL <br /> <br />Business Address: ~I S t}:1.. (; y C4 n ~ ~ r <br /> <br />O~ Jjl~/t <br />[City] <br /> <br />/3q y/~ I <br /> <br />,/VIA <br />[State] <br /> <br />;; F d ?fi <br />[Zip) <br /> <br />Business Telephone Number: ~~ 7' - tl Z b . 66 7l{. <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: ;vi r C It <^-( I w b, I~p" <br /> <br />Title: <br /> <br />(/ .;y t'Lb'" <br /> <br />Social Security Number: <br /> <br /> <br />Full Name: <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: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br /> <br />.--r <br />Corporation Name: fJ /11 A>v )-NG <br /> <br />dba <br /> <br />(~kr-".Jl~ ~(v~/ <br /> <br />Business Address: <br /> <br />~~ <br />