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<br />I <br /> <br />Incorporation Date: <br />List of Directors: <br /> <br />\ \ 11.1...> \ 0 "t. <br />'"1:'." -=' ~ 1 '7Q.cr.!, IP;.;); . <br /> <br />List of Stockholders: <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br />,......,... . <br />Applicant's Name: 1000 IN\.l~'- <br /> <br />Applicant's Address: <br /> <br />\.p "Ill,. ~iUI A r:> <br /> <br />s-...t'1~ <br />DIZ.. . <br /> <br />~~~ {vtr--:> <br />[City] [State] <br /> <br />Home Telephone Number: loSI \\"1-- l.:1?;S'L <br /> <br />5"SD7> 5 <br />[Zip] <br /> <br />Social Security Number: <br /> <br />i..{:(.,"l - 0'- - 1'2_<6 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 />0\ll< <br /> <br />Addresses: <br /> <br />lJl", <br /> <br />Assumed or Trade Names, if any: \..l i A <br /> <br />Business Telephone Number: N }I\- Home Telephone Number: ~ ~ <br />Has any person named in the application ever been convictedofa felony? 0 Yes 0 No <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />N r l\. <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 />Federal Tax Identification Number: <br /> <br />S"'~I..,..OS <br />'-{ I.~ 'Z.o1... \ \O~ , <br /> <br />Minnesota Tax Identification Number: <br /> <br />Signature: <br /> <br /> <br />tification Number is not required, please explain on the reverse side. <br />Position (Office, Partner, etc.): ?lUbIOe-"" , l\.,-,,",- <br />4(,,,, \O'L <br /> <br />Date: <br /> <br />Print Name: <br />