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<br />Incorporation Date: <br /> <br />Fd /~0 <br />/ ;:;~ /lId--r1 <br />/~A~ <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Security 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 ooder the license for which this application is made and describe their interest in detail <br />below. <br />~~'~'~-~--~._-~--.-'----------' <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />~~TelephoneNumber: 6-g 'J.-~ ro))YhomeTelephoneNumber: C:>. Sf-CaS] --08S1 <br />Has any person named in the application ever been convicted of a felony? D Yes '" No <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: . ']?, c,}. ;2 J f <br /> <br />FOOernI Tax ldentifiQltion Number. fj /- / S ,Sf (,77 <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />Signature: <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br /> <br />/tJ! <br />