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I, �1'� � ��C �� � • being duly sworn, depose and confirm that the <br />preceding sta ments are true and correct, and that this statement is executed with the knowledge <br />that misrepresentation or failure to reveal information requested is sufficient cause for denial or <br />revocation of a license; that I am voluntarily submitting this application with full knowledge tliat <br />Minnesota law provides that any person making false�th shal�guilty of perjury. <br />C �'1 f �-� (`�Gl;�'l.C'�I ��2 <br />` Title <br />Subscribed and sworn to before me this � � day of ���Q��'E��f�'in the year _�/ � <br />- ROBIN FRANKE <br />���',,�'�''' NOTARY PUBUC <br />T' MINNESOTA <br />�� = <br />_s My Commission Expires Jan. 31, 2D18 <br />(Please Stamp Here) <br />Page 10 oE 10 <br />�.{� ���( t. f � �(%� <br />Notary PuUlic <br />County of /`�����%�-l����'� <br />My Commission expires ����� ��� � � ��' <br />