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Page �5 <br />Full Name <br />LAST FIRST F17i.L ffiIDDLS NA�3 <br />Date Of Birth Interest <br />Residence Address <br />Residence Telephone <br />� <br />D. 'I'he full name, residenc� address and telephone number <br />of the manager, proprietor, or other agent in charge of <br />the individua7.'s, co�paration's or association}s <br />premises to be licensed: <br />FuI. �. Name <br />FIILL �dTDDLg NA� <br />Residence Addres� <br />Residence Tel�ph I.�� - <br />Date Of Birth <br />STATE OF <br />• •- 1• ��j� <br />sworn, upon ni� <br />person who has <br />statements made <br />belief. <br />r <br />, being first duly <br />oath, deposes and says hat he/she is the <br />cuted the above appl' ation, and that the <br />rein are true of '/h owledge and <br />SiGNA <br />Ghle� <br />TI <br />Subscribed and�a�aorn to before me thias Z��day of � b �' <br />19 ��'� <br />A��°�+�,, ANNAJ. PARIiGCINI <br />�,��,. > Notary Public <br />`- '� % State of Minnesota <br />y , P <br />� � ` �' �vly Commission Expires <br />_ ,,. � Januory 31, 207 8 <br />�� . � L � . <br />l <br />. •�: <br />1� �• / <br />/ � <br />My commission expires • �R �g <br />