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<br />Incorporation Date: 'I/; /~ ~ <br />List of Directors: C~f ~ ~ ~ <br />TeA? 0/- &v~. ~ <br />List of Stockholders: -4 ~ f/ - <br /> <br />- <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] [State] <br />Home Telephone Number: &S/- 7~-/d.s-6 <br /> <br />[Zip] <br /> <br />Social Security Number: _ <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 under the license for which this application is made and describe their interest in detail <br />_ __mum below_m n m_ _ ____.___m <br /> <br />~~tAta~ <br />/:Jg71fl~ wJJ . <br />Addresses: C~dh ,(Jh0@~ <br />/ <br /> <br />----------~~-- - <br />~ik-f~~~ <br />~~ .~5~ <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: tiS" J -Iftt...'I~/?1Y Home Telephone Number: U- /... 7 A:). /$"t::, <br />Has any person named in the application ever been convicted of a felony? 0 Yes 0 No <br /> <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: 7 t' /75. ,:;-1 <br /> <br />Federal Tax Identification Number: :2L:J - J 11/1.lJ b- d <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />Signature. <br /> <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br /> <br />J/j <br />