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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Number and the social security number of each license <br />applicant (person signing the ao{>lication). <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />are required 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 /> <br />2. Upon receiving this information, the license 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 <br />information to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: tJ r f ,S/; L (' <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />'-;6/?RA;tJ([ ::r:iI'JES (Y1btK <br />,Si./ <65 J S 7 I.!; S-1. ~ <br />JlU!?,:) /1/~ <br />[City] [State] <br /> <br />,C;S03f: <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />Lj7l 7J~ )6,-5 J <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />.~Sll JI"ILJK h1/(,) /),Ii/l. .. )A6;;/P~f )OdtJ;{Y <br />'1093 JtJ 7JJ. /)vf. So. <br />([/If{iP.,);lt [ <br />[City] <br /> <br />)11,11. <br />[State] <br /> <br />,5S !)]~ <br />[Zip] <br /> <br />Business Name: <br /> <br />Minnesota Tax Identification Number: <br /> <br />37371'1 ) <br />L//- /907Cf<l3 <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please e. lain on the reverse side. <br /> <br />9-/)9--00 <br /> <br />Date <br /> <br />