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<br />" <br /> <br />~o~~ooD~: ~\i~1 . <br />List of Directors: ~DD JV\\.~ ~ \ ?tZ.A'n\~~ <br />("t\~..... j~ VOK..~-n I \1. p- <br /> <br />List of Stockholders: <br /> <br />PERSO~~ INFORMATION (if sole proprietor): <br />Applicant's Name:. ~ VJi&~""'M <br />Applicant's Address: '!do. <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 />"'^\~ W~~ <br /> <br />1~l)() s:'~ <br /> <br />, <br /> <br />Addresses: <br /> <br />~B~ <br /> <br />lbQ-\1.-.C?.1- _ ~ <br /> <br />~~o <br /> <br />J un c. <br />I <br /> <br />, <br />8at.~ <br /> <br />Pa.. f'.no. UJ~\ \, _ <br />. \~I'" <br /> <br />Assumed or Trade Names, if any: <br /> <br />u v... ~t (' P'",:Z..04- <br /> <br />Business Telephone Number: 1,~3 \0,-, <br /> <br />Home Telephone Number: <br /> <br />,11- c;s. 3$ <br />0( No <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes <br /> <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 qualifications of a <br />licenSee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: -2J] ~?) ~"\ 'l.. <br /> <br />Federal Tax Identification Number: z.og 1'J h ~ w'5 a.. <br /> <br /> <br />Print Name: <br /> <br />is not required, please explain on the reverse side. <br />Position (Office, Partner, etc.): V\~/ 'X~!.)\ ~ <br />Date: "l, \01 <br />