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<br />Incorporation Date: /0./97 <br />List of Directors: l7o~ <br /> <br />List of Stockholders: (71)/2 r/' <br /> <br />Home Telephone Number: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br />Applicant's Name: J.< ir'hA-fh 4, ()c:-FT)(~>/ <br />Applicant's Address: ,':) g C;'O ~<6 /h) c/ <br />(/ I' r{~J~- P f (\C-:5 {11/1 <br />[City] [State] <br />6!~- 7?() ~,~9 (f <br />!-(77 - 70 -/ &7<{O <br /> <br />_~-j 0;1 <br />[Zip] <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 />b~ <br />.-1\,{',h~"d ,4 \ De-rDC <br /> <br />Addresses: .3 CJ su <br /> <br />'6 ~.---t1\ /4v'L-- C<.--fc--I C P / IICS In /) ~-') cJ If <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: t,:)/- VcJ 9 - 3033 Home Telephone Number: bid - 7~ o~ S9/ 1 <br />o Yes ~ No <br /> <br />Has any person named in the application ever been convicted of a felony? <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />Minnesota Tax Identification Number: <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 ~{3 <br />0- /h~ 3;;<:; <br /> <br />Federal Tax Identification Number: <br /> <br />If a MinnQ TV I1TMcfio~umber is not required, please explain on ~~everse side. <br />Signature~ 1\~eX.J U .( S _ _ Position (Office, Partner, etc.): -f//&<;/Ot.Jl1C:;- <br />Print Name;-R;c:..hA-l'd Oc:tf)C Date: I ty !j() /od <br />i I <br />