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<br />lnc.JlpOuillon Date: ( / ~ ~ I DB <br />l ' <br />Listof~J4.? C::;WlC\<t0sor-) <br /> <br />UstofStodtholders: ~rr.'PF.> gW~J-J'50"":> <br /> <br />P:lRSONAL INFOItMATION (If sole proprietor); <br /> <br />Applicant's Name: <br />Applicant's A~: <br /> <br />[City] <br /> <br />[Slate} <br /> <br />[Zip) <br /> <br />Home Telephone Number: <br />Social Sronity Number: <br />ALL APPUCANTS: <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 tbc liQense for which tIili! application is made lInd describe ~ir intetCSt in detail <br />below. ~ <br /> <br />~M~ D ~,.J <br /> <br />Addresses: <br /> <br />~1'S' I <br />\.ktcro <br /> <br />15'7 t.fi: c;;+ I 1-1. <br />~ ~O~A <br /> <br />Assumed or Ttade Names, if any: <br /> <br />Business Telephone Number: leoS-I -2 (1.1-'1 'Z.~o Home Telephone Number: (.,<::;/ - r../"tt./ - q~<J{J <br />Has any pcrsonnamed in the application ever been convicted ofafelony? 0 Yes ~ No <br /> <br />!fyeg, set furth the offense, date, county and stated of conviction: <br /> <br />Applicant agrees that any manager employed in the licensed p!eIltises will have all qualifications of e <br />licenBec and !bat tbe IIl31Ia8fl will not violate any city or stall: laws. <br /> <br /> <br />q2-4/?>4J <br />4 C;; - 0 S"BLD ~?, '-f <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax ldentiflcatWn NUJDber: <br /> <br />Si <br /> <br />required. ple3BC explain on the re'VefSC side <br />V~'ZS . <br /> <br />.tion (Office, Partner, e!o.): <br /> <br />( ('2-7, /(Jf <br /> <br />-46- <br />