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<br />Incorporation Date: <br /> <br />17<1 I <br /> <br />List of Directors: W j IAtCv~ ~J $'f)G <br /> <br />List of Stockholders: <br /> <br />. <br />PERSONAL INFORMATION (if sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] <br /> <br />[State] <br /> <br />[Zip] <br /> <br />Home Telephone Number: <br /> <br />Social Security Number: <br /> <br />ALL APPLICANTS: <br /> <br />List all persons or entities with either a direct or indirect interest in the applicant or the applicant's business <br />to be conducted under the license for which this application is made and describe their interest in detail <br />below. . <br /> <br />W//It~~ ~/$~e <br />'J~9 i ~ Ce,J ffr,;; Ilf <br />Addresses: CerJ ~& rJ , / If <br /> <br />Rei <br />}11r/ <br /> <br />6AJ. <br />P'5~3F <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: IPfI-653 -)p P / Home Telephone Number: d./2 ~ 5.ff"-tJ3tJ5 <br />Has any person named in the application ever been convicted of a felony? 0 Yes g 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 / 9 / tJ tJ <br /> <br />Federal Tax Identification Number: Lj / w / / tJ 7 } tJ ? <br /> <br />Signatnr : <br />Print Name: ttlf!r~ <br /> <br /> <br />ber is not required, please explain on the reverse side. <br /> <br />~, <br /> <br />Position (Office, Partner, etc.): <br />Date: / /)1;11 )ttJ.5 <br />, , <br /> <br />33 <br />