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<br />Incorporation Date: <br />...-;'""' <br />List of Directors: ~O~ <br /> <br />, \ ,\ 0'1- <br />~, <br /> <br />~:hO~ <br /> <br />List of Stockholders: <br /> <br />{\\~ <br /> <br />PERSONAL INFORMATION (If sole proprietor): <br />Applicant's Name: <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 />~(\O ~R~ \1a.n\o~ <br /> <br />Addresses: <br /> <br />('~1~ <br /> <br />~~~ <br /> <br />. <br />b~\V1 <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: ~~\ iju, c,.~DB Home Telephone Number: "Sl ~J"L-Z,SSL <br />Has any person named in the application ever been convicted of a felony? 0 Yes l1 No <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />"'lit- <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 Jaws. <br /> <br />Federal Tax Identification Number: <br /> <br />'S1oCS '-0<<; <br />L\\ "'1.02.\\lt~ \ <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Signalun:: ~ Position (Office, Partner. etc.): -.len. oa <br />Print Name: ~ Date: ,\ \ \S \Q~ <br /> <br />d1u <br />