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<br />Incorporation Date: <br /> <br />List of Directors: <br /> <br />List of StOckholders: <br /> <br />- -- <br /> <br />PERSONAL INFORMATION (If sole proprietor): <br /> <br />Applicant's Name: /1l&- ~ / f fA!./ Jvwy <br /> <br />Applicant's Address: It 1?,2- G ~~1 ~. <br /> <br />---0t'4 UA It ,.vJN <br />[City] [State] <br />C )l - 'l- J <i .... ~g'1-Z <br /> <br />s-' n LK <br />[~p] <br /> <br />Home Telephone Number: <br /> <br />Social Security Number: _ <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 descn1>e their interest in detail <br />below. <br /> <br />/J11~~1 ~/~ - I)UJ14b:' <br /> <br />Addresses: <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: /;(1- &(2-6- (;67" Home Telephone Number: G-~ - 1,""-11,12- <br />Has any person named in the application ever been convicted of a felony? 0 Yes )S No <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: <br /> <br />F~era1 Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Signature~~ Position (Office, Partner, etc.): lAc, ~ <br />.PrintName: ~~{ fW&-e,t~ Date: {O -- 1(- (J ~ <br /> <br />s~ <br />