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<br />Incorporation Date: ~\\)[ 'Z.CO~ <br />ListofDirectors: YtitDlJjJ1 C frJA-Pf:t <br /> <br />()v/WR./fte/OFNf <br />/ <br /> <br />List of Stockholders: JJ1JJlffH G fl1/1flJ:..'l<- <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 />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: <br /> <br />Home Telephone Number: <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Y es ~ 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: jtJO 6J B4 <br /> <br />Federal Tax Identification Number: "2 j- OZ.9, '5 2--13 <br /> <br /> <br />Sign <br />Print Name: JiI)[b;/I/I 6- N;Jf1/ <br /> <br />s not required, please explain on the reverse side. <br /> <br />[)k/Mt/ntJ//FlW <br /> <br />Position (Office, Partner, etc.): <br /> <br />Date: rP/f/o1 <br /> <br />13 <br />