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<br />Incorporation Date: . )v ~ <br />List of Directors: S~ a--:::J <br /> <br />?6>OY <br />I~r- J <br /> <br />14 he ~ <br /> <br />, <br /> <br />\" <br />List of Stockholders: <br /> <br />\.c. <br /> <br />\. . <br /> <br />\. ~ <br /> <br />/~ <br /> <br /> <br />I <br /> <br />ALL APPUCANTS: <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 /> <br />Assumed or Tmde Names, if any: <br /> <br />Business Telephone Number: b5""1 . i12. b" '-18 go Home Telephone Number: &~ {- fu. if 8'" )"D <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 Dot violate any city or state laws. <br /> <br />Federal Tax Identification Number: <br /> <br />10\ .,S-S-( <br />~tJ \ '\ 4 \ . \~L <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minneso~ Tax Identification Number is Dot required, please explain on the reverse side. 11 <br />Signature:( OJ-..~ \)~ Position (Office, Parmer, etc.): -P"....""~.;rJ <br />Print Name: tj).{tL ~,,~ l Ul-~ Date: i/")r~ UU-c,. <br /> <br />~ iv~d( <br />