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<br />CITY OF CENTERVILLE <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby certify under penalty of petjury that I have applied for an intoxicating Iiquor/on- <br />sale wine license and that the sales of such beverages are less than $10,000 per year, In <br />addition. I certify that the attached list of my wholesale suppliers is true and correct, If <br />necessary, these suppliers may be contacted in order to confirm this declaration. <br /> <br /> <br /> <br />I I r;;"3 / {)f <br />I I <br /> <br />i""""'- KA THl~tN K TflANDEM <br />i,\"'tt!! NOlary Public <br />'~~ Mrnne.sote <br />,lyCCiTl~~JinU8l)'3112011 <br /> <br />~A' -:13 ,:;OO~ <br />Dat~ <br /> <br />NOTE: A UST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY TIllS <br />DRAM SHOP EXEMPTION FORM. <br /> <br />-44- <br />