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<br />Form <br />SP:C1 <br /> <br />State of Minnesota <br />License Applicant Information <br /> <br />Under Minnesota law (M.S.270.72), the agency issuing you this license is required to provide to the Minnesota Commissioner <br />of Revenue your Minnesota business tax identification number and the Social Security number of each license applicant. <br /> <br />Under the Minnesota Govemment Data Practices Act and the Federal Privacy Act of 1974, we must advise you that: <br /> <br />. This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota <br />Department of Revenue delinquent taxes, penalties, or interest; <br />· The licensin9 agency will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange <br />of Information Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service; <br />· Failing to supply this information may jeopardize or delay the issuance of your license or processing your renewal <br />application. <br /> <br />Please fill in the following information and return this form aiong with your application to the City of Minnetonka. <br /> <br />Please print or type <br /> <br />Type of license being <br /> <br />applied for; <br /> <br />Personal information: <br /> <br />First name and Initial <br /> <br />Applicant's last name <br /> <br />Social Security number <br /> <br />Applicanfs address <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />Business information (if applicable): <br /> <br />Business name <br /> <br />Business address <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />Minnesota tax <br /> <br />identification number <br /> <br />Federal tax identification number <br /> <br />If a Minnesota tax identification number is not required, please explain on the reverse sfde of this form. <br /> <br />Signature <br /> <br />Title <br /> <br />Date <br />