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<br />Incorporation Date: <br /> <br /><s~ i- r~ <br /> <br />List of Directors: <br /> <br />-%/PlJi S46e/f <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br />~ -r .SA <br />Applicant's Name: I.t: IM;U( 2.- :]--1-.4/1 fS. 6 t~ <br /> <br />Applicant's Address: / Sf? S ) S ) Zj .) / fl/. <br /> <br />I/v 60 <br />/ [City] <br /> <br />,{<;)- '/07...- 7Jo) <br />. <br /> <br />1/7/-' .9), ./65') <br /> <br />)11/1.,< <br />, [State] <br /> <br />,J'fOJ \S' <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Security Number: <br /> <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 />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: <br /> <br />Home Telephone Number: <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes S No <br /> <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 not violate any city or state laws. <br /> <br />Federal Tax Identification Number: <br /> <br />~5737.9Y) <br />'1/- Iff) 79~J <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minne:.;.?" Identifica' n Number is not required, please explain on the reverse side. <br /> <br />Signature: V Position (Office, Partner, etc.): h is-I J f>v/, <br /> <br />Print Name: '~frJj?-1.1J{ f :;. }{6 V? Date: <br /> <br />/fJ- j - 00 <br />/ <br />