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<br />Incorporation Date: <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />.- -- <br />PERSONAL INFORMATION (if sole proprietor): <br />ApplicanfsName: Jl1lc hail 1 W~/Jvwr <br />Applicant's Address: It 'Cjz. G rp,,~1 At.t <br />(})7i [dAft <br />[City] <br />r;, )'1 - '1/1 <6 ,,- 5f?5'7 Z <br /> <br />,tVlN <br />[State] <br /> <br />S"'n~ <br />[Zip] <br /> <br />Home Telephone Number: <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 descnbe their interest in detail <br />below. <br /> <br />/11 (P ~/ wPJ,../iIWV" - OU.lh JY' <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: 6ft - 'f1-6- f;6'7r Home Telephone Number: ~:7t - ~1f-g-y,12- <br />Has any person named in the application ever been convicted of a felony? 0 Yes ~ 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: <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />Signature~~ Position (Office, Partner, etc.): O{,(, ~ <br />(AJ f -( (1M I~ {D.... ((-(')<':.. <br />PrintName: rll\~ .-. u.~ Date: / <br /> <br />d3 <br />