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<br />CER~ICATEOFCO~LMNCE <br />DEPAR~NTOFREVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Number and the social securitv number of each license <br />applicant (person sllrn'nt! the application). <br /> <br />'.tinderthe'Mi'miesota Government Data Practices Act aDd the Federal 'Privacy Act of 1974. we <br />are required to advise you of the following regarding the use of this information: <br /> <br />1. This infonnation 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 /> <br />2. Upon receiving this information, the license authority will supply it only to the <br />Minnesota Department ~f Revenue. However, under the Federal Exchange of <br />Information Agreement. the Department of Revenue may supply this <br />infonnation to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: \...\t'\M\ <br />~ <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />ro~~~ rr. ~V~n <br />~'D~~ \~~ C\-. N. <br />~ r(W. <br />[City] [State] <br /> <br />~~'8 <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMA nON: <br /> <br />~~ fto~~~1:) ~-tlA \).^~-p 1. <br />WBL 4~; {). <br />MH. ~O~.x <br />[City] [State] [Zip] <br />Minnesota Tax Identification Number: _S 1 e.':l m~ <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />JsB,~ <br />~~1\<:' <br /> <br />Federal Tax Identification Number: <br /> <br />'aO~~7..~ lQ52.. <br /> <br />If a Minnesota Tax Identification Numher is not <br /> <br />\O",~"'DL, <br />Date <br /> <br />, '",ff],"' '" , , '"I, <br /> <br /> <br /> <br /> <br />:. I. U <1' J . . <br /> <br />the reverse side. <br /> <br />v.v. <br /> <br />r. Owner, Partner) <br />