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<br />List of Stockholders: <br /> <br />FJ I g {p <br />/ p:J~ /l!~~ <br />/aJ~~ <br /> <br />Incorporation Date: <br />List of Directors: <br /> <br />- - <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 />ALL APPLICANTS: <br /> <br />List an 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 descnDe their interest in detail <br />below. <br /> <br />Addresses: <br /> <br />Assumed or 1iade Names, if any: <br /> <br />ihc4s Telephone Number: 6'9 ~~" I")} Yhome Telephone Number: ~. r / - W3 --Og5f <br />Has any person named in the application ever been convicted of a felony? 0 Yes '" 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 /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />Signature: <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br /> <br />10 <br />