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<br />Incorporation Date: S h / ~'/ ( <br />List of Directors: ~ ~ f!u.P- ~ <br />~c1~~ <br /> <br />List of Stockholders: ~S~ &;. <br /> <br />PERSONAL INFORMATION (if 1I01e proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] [State] <br />Home Telephone Number: ~/- /1~,;2 - / d. ~6 <br /> <br />[Zip] <br /> <br />Social Security Nnmber: _ <br /> <br />ALL APPUCANTS: <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 condncled llDder the license for which this application is made and describe their interest in detail <br />below. <br /> <br />fat-~-~~ ~ <br /> <br />Addresses: <br /> <br />/8'0 / 1J1~ >> . <br /> <br />Assumed or Trade Names, if any: <br /> <br />Business Telephone Number: Home Telephone Number: ~ -? t::2 -/ ~~ <br /> <br /> <br />Has any person named in the application ever been convicted of a felony? 0 Yes ;B;l No <br /> <br /> <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />~-- <br />./ <br /> <br />Applicant agrees that any manager employed in the licensed premises will have all qmlifications of a <br />licensee and that the manager will not violate any city or state laws. <br /> <br />Minnesota Tax Identification Number: ~ <br /> <br />Federal Tax Identification Nnmber: ~ <br /> <br />If a Minnesota Tax Identification Number is not reqnired, please explain on the reverse side. <br /> <br />Signatnre: <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br />