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<br />Incorporation Date: <br /> <br />111'l...""\0.... <br />--r.:"Oo ~ 1 ''?((.(Y.!,IP';..:>I-. <br /> <br />List of Directors: <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (If sole proprietor): <br />r'""7' . <br />Applicant's Name: 1000 ItV\.l~'-- <br /> <br />Applicant's Address: <br /> <br />1..,'11l.,. ~IUiA"'" <br /> <br />~?f-cs-> <br />DIL. <br /> <br />~",O:'-E'- fv\.f'.J <br />[City] [State] <br /> <br />Home Telephone Number: Ios\ \\.>l.... L~S~--- <br /> <br />S"'S()~'6 <br />[Zip] <br /> <br />Social Security Number: <br /> <br />It(.,o, ... 0... _ 1'2..'2 j <br /> <br />ALL APPUCANTS: <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 />1-1 \p< <br /> <br />Addresses: <br /> <br />I-llp< <br /> <br />Asswned or Trade Names, if any: \...) \ A <br /> <br />Business Telephone Nwnber: N JII- Home Telephone Number: ~I ~ <br />Has any person named in the application ever been convicted of a felony? 0 Yes 0 No <br /> <br />If yes, set furth the offense, date, county and stated of conviction: <br /> <br />N 14\. <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 violste any city or state laws. <br /> <br />Federal Tax Identification Number: <br /> <br />s-,o~\,..os <br />L{ 1- 'UYL \ \.,~ , <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minnesota Tax <br /> <br /> <br />tification Number is not required, please explain on the reverse side. <br /> <br />Position (Office, Partner, etc.): '?CL4b'O-e-l"T . U~v-...--- <br />4!'C\ \01... <br /> <br />Dste: <br /> <br />Signature: <br /> <br />Print Name: <br />