2002-01-09 CC Packet - Laserfiche WebLink

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I- I I I I I TAX CLEARANCE INFORMATION TO LICENSE APPLICAl"JT: Pursuant to Minnesota Statute 270.72 Ta.x Clearance: Issuance of Licenses, the licensing authority is required to provide to. the Mimlesota Commissioner of Revenue your "Nlinnesota Business Tax Identification Number and social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to allvise you of the following regarding the use of this information: 1. This informat[()n may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this infornlation to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the tollowing information and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. UCENSETYPE: Liq",.~ NEW [ ] I RENEWAL [Xl LICENSING AUTHORITY: City of Centerville / / /0-2. LICENSE RENEWAL DATE: BUSINESS INFORMATION: Business Name: Business Address: [City] [State] (Zip] Business Telephone Number: List of Officers or Partners (full name, title, and social security number): Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: IF A CORPORATION: Corporation Name: P"L) , ^ i ,- - I I Ii' I (0-( (;/ ,-. 71'1 dba ,>[-6, h,o",;;.- h [I <; ~, C Icb Business Address: 7;('51 /l1cl;/1 C.J -'T. c,,;,ti':c...\k /)/JA/ '5 so S X'