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<br />Incorporation Date: <br /> <br />;r ~~! I? /7!~A/7iJ-//J <br /> <br />Hv?- /J(P/l/7A-/A./ <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION fdsole proprietor): <br />. . . . . <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 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 descnbe their interest in detail <br /> <br /> <br />below. 44',( 4& /V 7/1/ d <br />Addresses: & .)/0 c:e~~ d!/J ;/?&. 97<- <br />L~ /~%eL~ ,#//V ~C:S'O:3/ <br /> <br />Assumed or Trade Names, if any: <br /> <br />C'"'--- <br /> <br />Business Telephone Number: Home Telephone Number: <br />Has any person named in the application ever been convicted of a felony'? 0 y es ~ <br />If yes, 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 qualificaiions of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: _ rs G ~ ~ <br /> <br />1-(,/ / S' ~ <br /> <br />:2/1 <br />~7 t, 17 <br /> <br />Federal Tax Identification Number: <br /> <br />Ifa Minne <br /> <br /> <br />ot required, please explain on the re& <br />. P~OD (Office, Partner, etc.): ~ <br />114.,: /1) ~J.~ -07 <br />