2005-12-14 CC Packet - Laserfiche WebLink

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TAX CLEARANCE INFORMATION TO LICENSE APPLICANT: Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the. licensing authority is required to provide to. the Minnesota Commissioner of Revenue. your Minnesota Business Tax Identification Number and social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise Y<?u of the follo~g regarding ~e use of this inf~rmation: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Deparbnent of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of '. your licensing issuance or ~ewal application. Please supply the following information and return along with your application to the agency issuing the license.. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. ;it LICENSE TYPE: ~ LICENSING AUTHO : City of Centerville J -J - 0 b IF . BUSINESS INFORMATION: Business Name: #l~ ~ ~ [)u?/J ~ ,_I . ~' ~ BSnessAdmess: ~~~~;{) ~~03Y cJ [City] [State] [Zip] Business telephone Number: 0 J - ;J. b f J. J Y. i NEW[] RENEWAL ~ LICENSE RENEWAL DATE: List of Officers or Partners (~~ title. and social security IDl~): Full Name: 'Z:21// L.. /f1 0 Il/ //j / ~ Title: A ~ Social Security Number: . Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: Full Name: Title: Social Security Number: IP A CORPORATION: Corporation Name: 11J~ ~~. J7Z0 <0fl7C tU- ~ hr- Business Address: ~c;