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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: 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: <br /> <br />OFf SAtL <br /> <br />NEW [ ] <br /> <br />RENEWAL LX] <br /> <br />LICENSING AUTHORITY: City ofCenterville <br />--5 J.~1' 1~, / <br />LICENSE RENEWAL DATE: ,AN, -- ctVV <br /> <br />Business Name: <br /> <br />BUSINESS INFORMA nON: <br />,)46tiP 5 /; &ve;,1 <br />7v93 dti1J JI(z/ f, L J <br /> <br />VI',/'; ;;AJ{//t { [ <br />[City] <br /> <br />;?11t/, <br />, [State] <br /> <br />,)S03<1S <br />[Zip] <br /> <br />Business Address: <br /> <br />Business Telephone Number: <br /> <br />15)- '1)j.-II);/ <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: ~;;..4 /lJ{ [ cJ:q/'1 fS "SA 6B:"f <br />Title: J1? f 5 ) <J f I'vj' <br />, <br /> <br />Social Security Number: <br /> <br />if7)- 9,J--/6S ) <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 />Corporation Name: -)A J1,PJUJ1C f;Ai { . <br />, <br />7093 J{)-a &v'I.,)O. <br /> <br />dba <br /> <br />,-~66:~S J/dJu/( <br /> <br />Business Address: <br />