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<br />CERTIFICATE OF CO:M:PLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance 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 />aoplicant (person si2:nin2: the application). <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 />1. 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 to 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 supply1lieji51lOWmgffl!ormatiofilmaretum-along wftJrY01lrappltclltton-:---n-- ~._~- <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: 1- I QUo R <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />(el1ne;rn F l/AJJOe.tt'8ee.K. <br />689~ Cel1-reRvlU:!" <br />Cenrerfli/"{"~ mAl <br />[City] [State] <br /> <br />~o <br />55 cJ3 8 <br />[Zip] <br />I <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />JOrlS-05 <br />Date <br /> <br /> <br />~ 19nature and Position (Officer, Owner, Partner) <br /> <br />If a Minnesota Tax Identification Number is not r~quired, p. <br /> <br />//1 <br />