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<br />TAX CLEARANCE INI'ORMATlON <br /> <br />TO UCBNSBAPPUCANT: <br />~ to MlnIN!!iltJlB _ 270.72 Till Cleeaaaao: Issaaaae of LfaeDses, the "-"'I audtorlfr Is <br />required to provide tit dae Mfn.-* Onnlll"""" of ~ JCIID' ~ p...r.__ TIll <br />ldMIfIfIftldfmI Nmahatr IIDIl socIaIlIIlCIId1.y IIUIIIher ofeaah IklIDse epp"-'t <br /> <br />Umlerthl ~ Gcr.v.wuua4 DalaPl'allcell Act 8Dd the Pedend PIiYIIDJ Act of 1974, we 1ft requINd <br />tit advfse JOU ofthl foJJDwI1Ig .....cLa tile use of this 1.II~...s..tLm: <br /> <br />ThIs hI6.~llIIIffon may be used tit _die ~ IIIIIW81 or traDsfer of your <br />IlaeDse In tba CMIIt JOII owe dae ....I..~ Dapalbuwl ofRavlmlm cIoUmpamt <br />lIDs. ~ or Iat&nsI; <br />Upcm JOClOIvID& tbfs I..I.....M''''\ the "-fIts a.dbor.Ifr wD1 supply.1t 0Dly to the <br />MImleso1a Dopbum4 of Kcvame. 1L.....1Ilr. tmder 1b Pedcnd BloftI",~ of <br />ItlfbllmdloJ ~ dae Dep.t1meD1 of.ReveDalllll)' 8IIpp1J t1ds J"I.....I- <br />tit the ID1IlrDa1 R.tMmuo ScrYIcL . <br />PaU11t8 tit 8IIpp1J t1ds IwIf'ol.....L.n may jeop.adB or deJay till pnl D~aI"I of <br />JOIII' 1faa..... fssuaaae ornmawal ~_____. ._ <br /> <br />Please supply the fbJlowJDs IDtl...lIAIlmr. aDd reIIIm aIcms with your Wlmd{lm to ., IIpDGy Js:sufDs the <br />Jfamse. DO NOT lIETIJRNTO TBB DBP.t.1l'I'IIIDIT OJ' IIIW~'" <br />, <br />LICENSBTYPE: _~nfl, NEW [X! RENEWAL [ ] <br /> <br />LICENSING AUlHORlTY: Cl\Y ofC'.8IbmIIIIe <br /> <br />LICBNSBRBNBWALDATB: ,\ \ \0' <br /> <br />I. <br /> <br />2. <br /> <br />3. <br /> <br />,,-,, <br /> <br />JII7SJNBSS INJ'ODL\TIONc <br />R\oAIlI_Name: S'....~ 1>1l.4f1e.+~~ I $-e. ~ <br />R\..III,,-Addnss: 1 OC\~ i..~ A.,,, S. <br />~WM:\" <br />[CIty] <br /> <br />. <br /> <br />~,....~ f:2,.'t.~ <br /> <br />B...d..~ TeJayItone Number: <br /> <br />~ <br />[SfIde] <br />(,,\ \ - ~C)2) OIr:P\"L <br /> <br />-S-SO"6~ <br />J;ZIp] <br /> <br />LIst ofOfBcers or ParIDerB (tbUllIIIIIO, 1Itle.lIIld social secarfty 1IIIIIlber): <br />P1I1lName: ~'Oo t'\.~e "" Stl,~ <br /> <br />Title: Soaial SecudtJ Number: <br />PUUName: m\~ ~G\~ ~<*\ <br /> <br /> <br /> <br />Title: <br />P1I1l Name: <br />Title: <br />PuD'Name: <br />TItIi: <br /> <br />SooIal Seaurlty NuaIber: <br /> <br />SooIa1 Seaurlty NuaIber: <br /> <br />SooJa1 SeCurIty NambeJ: <br /> <br />II' ACOBPOBATIONI <br />CaIpcmdIonName: ?#.\- ~~~, ~ dba \.)".."'" ~ ....'" <br />BusIIlIssAddnss: ,o,,~ 'lAia- ~ . ~. ", <br /> <br />~() <br />