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<br />Incorporation Date: <br /> <br />r:--- <br />~~1 <br /> <br />I 2' ~ <br /> <br />List of Directors: <br /> <br />- <br /> <br />~ <br /> <br />List of Stockholders: <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 /> <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 /> <br />below ~ <br />. /ftt~ <br /> <br />Addresses: <br /> <br />?s/o &n~~A 4 <br />~ &~_~ /lAJ , <)~5"o .--SP <br /> <br />Assumed or Trade Names, if any: <br /> <br />~ <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 Y es ~ 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 />3~t. ;;2 ::ZIP <br />Lj / - IS,S-7 C9j <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />ent" lcation Number is not required, please explain on the reverse side. <br /> <br />Signature: Position (Office, Partner, etc.): ./ ~ ~ <br />Print Name: fi~i /Ill) j!/7--1/# Date: ~;2 2?' ,;1 0 c9 2> <br /> <br />