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<br />List of Directors: <br /> <br />-te\I/01 <br />V\. r~. <br /> <br />Incorporation Date: <br /> <br />List of Stockholders: <br /> <br />t\\~ <br /> <br />- - <br />PERSONAL lNFORMATION (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 />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 the license for which this application is made and describe their interest in detail <br />below. <br /> <br />________~~______~:-~~~-~-~~~ ~~----h-- __ ____________~________ _ _______~_____ ___ ___~________ __ <br /> <br />Addresses: <br /> <br />. <br /> <br />"a Ct,"1b t(l,(.~ O'lt. <br /> <br />~ru:,H(" ~,.h <br />, <br /> <br />Assumed or Trade Names, if any: <br /> <br />~/~ <br /> <br />Business Telephone Number: \,~\ '1'l.~ ~ Home Telephone Number: 6S\ ib'Z.. Lc;~"'l. <br /> <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 />Federal Tax Identification Number: <br /> <br />570St:,()S <br />4l -1.01.. \~~ \ <br /> <br />Minnesota Tax Identification Number: <br /> <br />Signature: ~ <br />Print Name: \ ()OO <;:"1Z\(!fW <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />~~\o;,J- <br /> <br />Position (Office, Partner, etc.): <br />- Yt) \1., ~ OJ' <br /> <br />15 <br /> <br />Date: <br />