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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Number and the social secnrity number of each license <br />applicant (person sil!ninl! the application). <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use of this information: <br /> <br />1. This information may be used to deny the issuance, renewal, or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or interest; <br /> <br />2. Upon receiving this information, the license authority will supply it only to the <br />Minnesota Department Qf Revenlje. However, under the Federal Exchange of <br />Infonnatiort' . Agreement, the :department of Revenue may supply this <br />information to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: ()rr' SA/..G <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />ft11C/'U/ <br /> <br />r <br /> <br />W/t~MA-,e <br /> <br />Applicant's Address: <br /> <br />'Ifi1,L <br /> <br />Oa!<dPf/~ <br />[City] <br /> <br />51"?1 nd'l <br /> <br />/l1Ai <br />[State] <br /> <br />A-ve <br /> <br />S5/Z-f{ <br />[Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />C-enr-eAl/t/AA; ttCjliO r~ <br />10'13 ,).,fJ"'" Ave s. <br /> <br />Business Address: <br /> <br />Cevrrt.R /II Uf' <br />[City] <br /> <br />;I!).AJ <br />[State] <br /> <br />SS()3~ <br />[Zip] <br /> <br />Minnesota TmcIdentificationNumber: &3 - O?~ 5' '168 <br />Federal Tmc Identification Number: b 8 707 ~ r <br /> <br />If a Minnesota Tmc Identification Number is not required, please explain on the reverse side. <br /> <br />")./ }..-?-~CJ 1- <br />Date <br /> <br />~ 7f Wa-e.- <br /> <br />Sigh ture and Position (Officer, Owner, Partner) <br />