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<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 infonnation: <br /> <br />1. 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 />Inforn1ation Agreement the Department of Revenue may supply this information <br />to the Internal 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: () ff ~ A l.,C' - L1 &. Ij 0 I- <br /> <br />NEW [ ] <br /> <br />RENEWAL [v( <br /> <br />LICENSING AUTHORITY: <br /> <br />City of CenterviIIe <br /> <br />LICENSE RENEWAL DA TE: <br /> <br />/-/- ~ <br /> <br />BUSINESS INFORMA nON: <br /> <br />Business Name: ~ +e-I'lrli {LL l (4 vo.r <br /> <br />Business Address: 70 t) 3 d-cv ih ~ <br />C~ 4-vJk ! <br />[City] <br /> <br />"3 a,.,-1 <br />)' <br /> <br />j/JjJ <br />(State] <br /> <br />j)O 3 $; <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />j;-::;c ~ Li'"2-G - ~ 6'7 '-1 <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Socia! Security Number: <br /> <br />IF A CORPORATION: <br />G /r-Avv :C/'w C <br /> <br />10'7; 1-0 'f1 ~)' <br /> <br />dba <br /> <br />C~n..ivvll iL 47,;/111 &,,- / <br /> <br />Corporation Name: <br /> <br />Business Address: <br />