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<br />Incorporation Date: <br /> <br />n/z-~/o3 <br />I , <br /> <br />List of Directors: <br /> <br />List of Stockholders: /v} J l Ita e-/ <br /> <br />11f,{J111,tj. <br /> <br />/;vii /'>l4~ <br /> <br />PERSONAL INFORMATION (if sole proprietor): <br />Applicant's Name: fv1 {c h './.tI r'huV/1,Vtj <br />l/lY'f2 P'rn h.,..Itfj A..t <br />Applicant's Address: "10 - ~ ., /-p' <br />DOl ko!ftle <br />[City] <br />6>/- 330- -1,,00 <br /> <br />Wi71/""J Pi r <br /> <br />.M.N <br />[State] <br /> <br />5-.>"/2-8' <br />[Zip] <br /> <br />Home Telephone Number: <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 Yes I2l No <br />~ffense, 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 Jaws. <br /> <br />Minnesota Tax Identification Number: <br /> <br />B'b ~ 6 87 07S-~ <br />'9~ - 0 ~~ ~'fb8 <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: ~;j W~ Position (Office, Partner, ete.): O"'M-". <br /> <br />Print Name: 14,,,hlUl t Wql"I'J'V Date: <br /> <br />J.-"l-""}' -04 <br />