2007-11-28 CC Packet - Laserfiche WebLink

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TAX CLEARANCE INFORMATION TO LICENSE APPLICANT: Pursuant to Minneso~~tatute 270.72 Tax: Clearance: Issuance of Licenses, the licensing authority is required to providClO- the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification. Nwnber and social security number of each license applicant Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this infonnation: I. This information may be used to deny the issuance; renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this infonnation, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Infoiniation Agreement the Department of Revenue may supply this infonnation to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following infonnation and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. LICENSE lYPE: ~ NEW [ ] LICENSING AUTHORI: City ofCenterville ~I/f/l? I RENEWA~ LICENSE RENEWAL DATE: ;l.f}otf I I . , ! Business Name: ~ : I Business Address: Business Telephone Number: ?-)/-- ~. [State] Cf)b - ;LX ~ Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: .7T4~