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<br />Incorporation Date: <br /> <br />Iz.lo\ <br />'b~ ~\ <br /> <br />~\~ <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (ifsole proprietor): <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 />below. <br /> <br />'\bllO <b'\ef~~ <br /> <br />Addresses: <br /> <br />~~'i "'" P.>4t c. ~ t:ta. <br /> <br />~~,\~ 1 jV\,J <br /> <br />Assumed or Trade Names, if any: <br /> <br />r lS"'U\AJ.. 'Bt~) <br /> <br />Business Telephone Number: ~S\ 4~ It,ltO/?) <br /> <br />Home Telephone Number: <br /> <br />~ <;\ Ib'Z.. ZSS" 2- <br />~ No <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes <br /> <br />Jfyes, 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 />Minnesota Tax Identification Number: <br /> <br />z:;.1o <<;I..,.. c S <br />4\ - "Z.o 'Z. \ V; \ <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Signatme: ____ Position (Office, Partnor, ....~ ~{t<;!.\ ~ <br />PrintName~~ Date: \l\4D1 <br />