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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Miilnesota Statu',c 270.72 Tax Clearnnce; Iss\llIIIce 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 />wplicant (uerson BiminI!: the spplication). <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use of this information: <br /> <br />I. 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 /> <br />2. Upon receiving this information, the license authority will supply it only ro the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement, the Department of Revenue may supply this <br />information 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 infonnation and return along with your application: <br />TIPE OF LICENSE BEING APPLIED FOR OR RENEWED: <br /> <br />PERSONAL INFORMATION: \) <br /> <br />Applicant'sName: ~O\"<l{A."5 ()) 1SL<.)AI0S010 <br /> <br />Applicant's Address' S 15 I I S I -t} ~ T._JJ <br /> <br />\-4u.Qn MN s5"03~ <br />[City] \ [State] [Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />\ - <br />}(GLLY-S I<OlZ-~LrL Or:;. e.~AJTU2UI <br /> <br />~B ('c.:;-M5T?"reni'le:; e1:. <br /> <br />c.GI0I"L.a.U (LlC; MtJ ~S"Oi5g <br />[City] [State) [Zip] <br /> <br />Minnesota Tax Identification Number: ~ l. L\ \ ~ L\ I <br /> <br />we... <br /> <br />Business Address: <br /> <br />Federal Tax Identification Number: <br /> <br />~- Os.q(p ~~~ <br /> <br />If a Minnesota Tax Identification Number is <br /> <br />-.J i;)'3 /OP:, <br />t Date I <br /> <br />- <br />, <br /> <br />I <br />.-- <br />";"I <br /> <br />gnarure <br /> <br />( <br /> <br />) <br /> <br />-42- <br />