Laserfiche WebLink
<br />Incorporation Date: <br /> <br />d- /6 - )006 <br /> <br />List of Directors: <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 APPUCANTS: <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 />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: '5J ...6JJ. 771'J Home Telephone Number: 6J/w yo 7-7:J.QJ <br />Has any person named in the application ever been convicted of a felony? 0 Yes ~ No <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 alJ qualifications of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: <{ :J - OS 0 sa <br /> <br />Federal Tax Identification Number: ;) 0 - ,/l'lJi J~ <br /> <br /> <br />Signature: Position (Office, Partner, etc.): <br /> <br />Date: //J..jIJ')oQ/ <br />