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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: ----=r;; bn (J!' n NEW [ ] RENEWAL [/ <br /> <br />LICENSE RENEW AL DATE: <br /> <br />City of Centerville <br />JC\f\ \1rl,Ju I. dCO \ <br />~ <br /> <br />LICENSING AUTHORITY: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />ry\,J <br />[State] <br /> <br />5S'ol S <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: Wtt..H,QQ (<.0 bz!+- Pe th4- <br />Title: PreS \'cl~I\,-t )0 \;).,,-er Social Security Number: ~iJ h--\o~ ~Yd. Lf <br />f <br />Full Name: rY\a-rI ef\ ~ C\O--re.. Pe.+t1 t <br />Title: \1 \ ~ P (e ~ ,de.^ \- <br />Full Name: LMu(\:e, \("u.-ts.o.'''\ <br />Title: l\(('.(\s;','j Gc,~cl, <br />Full Name: <br /> <br />Social Security Number: ~ f 7 -~J - 5/8 L( <br /> <br />Social Security Number: lj/~- 8.;1- ;),;).8 Lf <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br /> <br />Corporation Name: ~iY\ll\\Ji1\ b <br /> <br />Business Address: <br /> <br />\ f3 (J [ rf'\Cll ~ <br /> <br />D' c. . dba ~'Yl llt wnh it ;;;q s- <br />~+ CerrW"IJ:ll-{. IY'\fJ Ssc3B <br />