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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant. <br /> <br />Under the Minnesota Goverrnnent Data Practices Act and the Federal Privacy Act of 1974, we are reqnired <br />to advise you of the following regarding the nse 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 de1inquent <br />taxes, penalties or interest; <br />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement the Department of Revenue may supply this information <br />to the Interna1 Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO TIIJj; DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: <br /> <br />NEW.P4- <br /> <br />RENEWAL [ ] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />.{'//o7 <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br />BnsinessName: ~ ~ <br />Bnsiness Address: I 'i5 CI / m ~~ ..g;f <br />~.~ S5o.3g <br />[City] ./ [State] [Zip] <br />Business Telephone Number: 1",0/- Lf e' / - f/7lf L.f <br /> <br />J... <br /> <br />List of Officers orPartoers (full name, title, and social security number): <br />FnllName: f!J c:I MI<. ~ <br /> <br />Title: P A...t4 Social Security Number: . <br /> <br />FnllName: I~J-,";" ~I ~~ <br />r? 17 {/ <br />Title: 1/. P. Social Security Number: <br /> <br />Fnll Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Fnll Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br /> <br />Corporation Name: ('t?~ ~ .LJ..t:.. dba <br />l'f5o / fYJ~ ...f-J. <br />--?I.fJ~ /~!7b--C3'? <br />/ <br /> <br />Business Address: <br />