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<br />I- <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />Incorporation Dare: <br /> <br />1(1'1 () <br /> <br />List of Directors: <br /> <br />'~, C/n+eJ\ <br /> <br />bE~~ <br /> <br />List of Stockholders: <br /> <br />Applicant's Addtess: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />Applicant's Name: ~~<.h.ru A. hefJ.V4 <br /><{'{ 11 A-.; " <br /> <br />f~ <br /> <br />3'150 <br /> <br />e (K'.U "- <br />[City] <br />76"5 .~ 7'[6 r <br />177 ~ 70 <br /> <br />11.u , <br />[State] <br /> <br />'50 t'-/ <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />)'71 ~ <br />.- (,150 <br /> <br />Social Security Number: <br /> <br />ALL APPLICANTS: <br /> <br />List all person.s 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 />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Nomber: liP 5/ J ,(J'I- 503') <br /> <br />Home Telephone Number: <br /> <br />Has J.ny person Ilamed in the application ever been convi~ted ofa felony? 0 Yes <br /> <br />l'4. 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 Imvs. <br /> <br />~tinnesota Tax Identitication Number: <br /> <br />UY;4B <br />Y/- /11'';) >>as <br /> <br />Federal Tax Identification Number: <br /> <br />Ira Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />Signature: <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br />