2007-11-28 CC Packet - Laserfiche WebLink

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--..--' ..- - TAX CLEARANCE INFORMATION - TO LICENSE APPLICANT: Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is required to provide to 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 information: 1. This infonnation 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 information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the FederiU Exchange of Infotniation Agreement th~ 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 information and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. LICENSE TYPE: --=Jt> ~c..u::> NEW [J RENEWAL [)(" LICENSING AUTHORITY: City of Centerville vN~ LICENSE RENEWAL DATE: Business Name: BUSINESS INFORMATION: ~(\.O'I'- l~~ ~..tMv=l~ &P/LlS"S~ I 'wh ~ <b."t 'w \ Business Address: [City] fva,...} [State) ~~\..- 42~.... ~ c,.D<<6 S'SD3~ [Zip) Business Telephone Number: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: IF A CORPORATION: Corporation Name: ..,-;L~~... I .x;" &.. Business Address: \ ~~o ""-A-,:"'> r\ . 'C1 _ dba '-..i"allO\'\. "-A'~S <;'T... c.~;He