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<br />Incorporation Date: <br />List of Directors: W I LJ, Cv Yh.- <br /> <br />/79 I <br /> <br />Pi s-Z;)G <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br />Applicant's Name: <br />Applicant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Security Number: <br /> <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 descn1>e their interest in detail <br /> <br />-----^--~--below~--~-----_--~~---------- - <br /> <br />w/ilt~~ ~/5~k <br />'Jt?9 i ' Ce,J fer-v; lie ;lei <br />Addresses: Ce,J ~& ,J L II f yt1 rol <br /> <br />6d~ <br />55/JpF <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: jpf/ w 653. ) P ? / Home Telephone Number: 6/2....5.>;t -tJ3 LJ '5 <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: / S I 9 It) tJ <br /> <br />Federal Tax Identification Number: 'II - / ) IJ 7} tJ ? <br /> <br />Si <br />Print Name: tJll!~ <br /> <br /> <br />ber is not required, please explain on the reverse side. <br /> <br />~, <br /> <br />Position (Office, Partner, etc.): <br />Date: / ~ /.1 / )CJ.5 <br />, ,. <br /> <br />9tJ <br />