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�.. <br />� <br />City of Roseville <br />Community Development Department <br />2660 Civic Center Drive Roseville, MN 55113 651-792-7080 <br />LICENSING INFORMATION <br />Notice: Pursuant to Laws of Minnesota, 1984, Chapter 502, Article 8, Section 2(270.72) (Tax <br />Clearance; Issuance of Licenses), the City of Roseville is required to provide to the Minnesota <br />Commissioner of Revenue the Minnesota business taY identification number and social security number <br />of each applicant. <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are <br />required to advise you of the following regarding the use of this information: <br />This information may be used to deny the issuance or renewal of your license in the event you <br />owe Minnesota sales, employer's withholding or motor vehicle excise taxes: <br />2. Upon receiving this information, the City of Roseville will supply it only to the Minnesota <br />Department of Revenue. However, under the Federal Exchange of Information Agreement, the <br />Department of Revenue may supply this information to the Internal Revenue Service: <br />3. Failure to supply this information may jeopardize or delay the processing of your license <br />issuance or renewal application. <br />Please supply the following information and return it along with your application to the licensing <br />authority. <br />Appli�ant's Last Name First Name Middlc Initial <br />Applicant's Address City Staze Zip Code <br />Applican['s Social Sccurity Numbcr Position (OfBccr, Putncr, ac.) <br />Businas Name <br />Businas Address Citp Staze Zip Codc <br />Minnesata Tax idrntification Number <br />Signature Date <br />