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<br />Incorporation Date: <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONi\L INFORMATION (if sole proprietor): <br />Applicant's Name: J1a ku,/ 7 Lv A-c,,N'I.,f?L- <br /> <br />Applicant's Address: l{ g 9 z, G rtt ~ Av <br />a tJ Ih I.R f'TA,v <br />[City] [State] <br />b)/- L(},~ - (;,6 71( Wo-'~ <br /> <br />5' 57. ~~ <br />[Zip] <br /> <br />Social Security Number: <br /> <br /> <br />t-H- """" <br />6'); ~ L-79'- ?,Y;72- <br /> <br />Home Telephone Number: <br /> <br />ALL APPLICANTS: <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 />MlCtwl <br /> <br />- I., ~ 1.,./1' /. <br />I vv f ,,,'AI"\.A1L- ... vv / . <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, jf any: <br /> <br />Business Telephone Number: b~r -l{2{. 6{7 'f Home Telephone Nwnber: 6(1'17;:-' f~7L- <br />Has any person named in the application ever been convicted ofa felony? 0 Yes e( No <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: b ~ 10 7 r> <br /> <br />Federal Tax Identification Number: K J .... OJ <g S- V ~ ~ <br /> <br />If. M"~on Number is ootroquirod, pJea.a explain on tho""""" .ide. <br />Signature: /l M Position (Office, Partner, etc.): ~ <br /> <br />Print Name: (b " .3 , . 7 Date: <br />m I C/ ha,( i W kV.A-t~ <br /> <br />IO-S'.7 <br />