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<br />Sh/ /c;q' ? <br />. <br /> <br />List of Directors: ~..; ~ ~ <br />~c/~~ <br /> <br />List of Stockholders: ,,45~ &--- <br /> <br />Incorporation Date: <br /> <br />PERSONAL INFORMATION (If sole proprietor): <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />[City] [State] <br />Home Telephone Number: ~/ - 7 t:,,;l- /.;2.176 <br />Social Security Number: .-. <br />ALL APPUCANTS: <br /> <br />[Zip] <br /> <br />List all persons or entities with either a direct or indirect interest in the applicant or the applicant's busioess <br />to be conducted under the license for which this application is made and descn1le their interest in detail <br />below. <br /> <br />~~~-~~~ . ==-' <br />~-'-'-_._-~-'~~ -~~~~'--~~-~------~-~~._~~-~_.-~.~.-------'-~~.~.~~---_.__.__.' . . -- ..-- <br /> <br /> <br />/8"0 / /J1~ 4i. <br /> <br />Addresses: <br /> <br />Assumed Of Tlllde Names. if any: <br /> <br />Business Telephone Number: Home Telephone Number: ~ -?~;2 -/ ~~ <br />Has any person named in the application ever been convicted of a felony? 0 Yes ;E;t No <br />If yes, set forth the offense, date, county and stated of conviction: <br /> <br />-------- <br />/ <br />. <br /> <br />Applicant agrees that any manager employed in the licensed premises will have all qualifications of a <br />licensee and thaI the manager will not violate any city Of state laws. <br /> <br />n-".J~O <br />Minnesota Tax Identification Number: ~ <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: <br /> <br />Position (Office, Partner, etc.): <br /> <br />Print Name: <br /> <br />Date: <br />