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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Oearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Nmnber and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use of this infonnation: <br /> <br />I. This infonnation 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 />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, 11Dder the Federal Excbange of <br />Information Agreement the Department of Revenue may supply this information <br />to the lntema1Revenue 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 infonnati <br />license. DO NOT RETURN TO ~ <br /> <br />UCENSE TYPE: <br /> <br /> <br />NEW p4... RENEWAL I ] <br /> <br />UCENSlNG AUTHORITY: Citv of CentervilIe <br /> <br />LICENSE RENEWAL DATE: ~/Jk7' <br /> <br />- -~,--=-'--.:::=-.::BUSJNESSJNli'ORMATION:==-==-==== ---=::=======------'------=-~_=___=-..::c_-=- <br /> <br />Business Name: ~ ~ <br /> <br />Business Address: I '3' t7 / m ~'- -?I <br /> <br />~. ~ 5503g <br />ICity] ./ IState] [Zip] <br /> <br />Business Telephone Nmnber: t,S 1- l( e 1- ?? if Lf' <br /> <br />J.. <br /> <br />List of Officers or Pamlers (full name, title, and social security number): <br />Full Name: f!~ cL I3uU ~ <br /> <br />Title: f A.-e4 <br /> <br />Full Name: I ~j,., a/- <br />{F <br />Title: l/. P. <br /> <br />Social Security Nmnber: SC;l.. -'T? -;1/0 / <br />~i~~ <br />{7 tf/ <br /> <br />Social Security Nmnber: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Nmnber: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Business Address: <br /> <br />IF A CORPORATION: <br /> <br />Corporation Name: ('t:?~ ~ l.U dba <br />1'8'0 / pJ~ .-V-. <br />.-tf . jJ~ ~.~ !>6c/ 3 f? <br /> <br />~-------------- - - <br />