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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to. advise you of the following regarding the use of this infol1ll31;ion: <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 />2. Upon receiving this information, the licensing 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 information <br />to the Internal Revenue Setvice. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br />LICENSE TYPE: Lit ~.1 /} r NEW [ ] <br />LICENSING AU1HORITY: City of Centerville <br />---. -- m'_ '.---. -'LiCENSERENEWACfiAfE:---.91~Tuml~--ui"t7t' tp-------------~----~-- - - --------------~--.. <br />BUSINESS INFO~?ON: <br />Business Name: ./ it / ~ is J~ I" rl i (' : ~. <br />Business Address: J ~ 98'- Ce rJ h /' II t / If Jivl <br />C;~ I-t /'r/: / If, /f1,.; <br />[City] [State] <br />Business Telephone Number: J; 5/- 65.5 - ~ 9 9 / <br /> <br />RENEWAL rXJ <br /> <br />:5.5/J 3 g <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: WI /114-~ 51St ic <br /> <br />Title: t (. s <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: ;d / /y;' /d;,,/'I E'" ~. dba <br /> <br />/~//y; h/'~~r <br /> <br />. <br /> <br />Business Address: <br /> <br />J9 <br />