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<br />Incorporation Date: <br /> <br />J:'t, <br />/ <br />1(' <br /> <br />);1& 1'<./ 7--1/1\.) <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />I'If It' L <br />, - <br /> <br />/lip A/IA f)'l/ <br /> <br />PERSONAL INFORMATION (If 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 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 /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: ?"~\)- 'f J b . :J 9..rL Home Telephone Number: ~)" 1- ts .}. D f-!J <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 />Minnesota Tax Identification Number: <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 />3& ?~7-Jf <br />,/S __f:;? t 7; <br /> <br />LJI <br /> <br />Federal Tax Identification Number: <br /> <br />Signature: <br />Print Name: ~<<,( <br />, - <br /> <br />.~ I~.. t~,. <br /> <br />not requUed, please explain 00 the """""'11. <br />Position (Office, Partner, etc.): p~ <br />;JIG ,rLr7,/f /Vate: /1-- 7- () { - <br /> <br />If a Minne <br /> <br />cd! <br />