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<br />" <br /> <br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification. Number and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we' are required <br />to advise you of the following regarding the use of this information: <br /> <br />I. This information may be used to deny the issuance, renewal or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties or interest; <br />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Infoiniation Agreement th~ Department of Revenue may supply this information <br />to the IntelnaJ. Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: ~V\dr NEW [] RENEWAL [)(1' <br /> <br />LICENSING AUTHORITY: City ofCentervilIe <br /> <br />LICENSE RENEWAL DATE: ~ ~ ~, Z-.a:J5 <br /> <br />BUSINESS INFORMATION: <br />~\O~elJ o~,4 <br />20m ,4~. ~. <br />[C~-kt-y\' lk.r rrL'ti <br /> <br />Business Telephone Number: \0 '5 \ - ~ ^ 1t'17 <br /> <br />Business Name: <br /> <br />~r~~ <br />1(A15 <br /> <br />VJI~IJ ~;27PJ <br />{J{)7?J F <br />[Zip] <br /> <br />Business Address: <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />\..tA)~ n <br /> <br />Full Name: ffi,~ '"$a.~~ <br />Title: \}~CK/ ~'~~l<kv'+- <br />Full Name: c-J;OO 1"\ l~ <br />~'E. ~.- <br />~ <br /> <br />Social Security Number: <br /><;"\6YPeN <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: 5~ V~~"""'~ <br />Business AddreSs: \ t:t~O M.A- l ~ <j)1' ". <br /> <br />dba UJ\~t.A'I~ <br />c..e.sr~I(.,~~ <br /> <br />~ 1 t...-z.q <br />(M-.u <br />