|
� Minnesota G�portr�oo-i of 1'ublic �i�e�}� ,� �
<br />�T ALCOHOL & GAMBLING B[�iEYM��."$MTNT DIVISION ���
<br />� '.� � 444 ��� SI�, �ui1� 1��, Si. �nul. MN ��:�:-�J�� ��. Y ' i:
<br />(651) 296-6439 TTY (651) 282-6555 �k�"�
<br />�;T�� www.�ps,sluke.n}is�kiX�����I1dkr�IC�f�fk7f}.ISIil7� F�� =F���
<br />� �i .
<br />�v��� or ���a�u�r�o�v � n����v ����n i•��
<br />F�rmt� F� � I � �i�enewal I��t�; �r�il � �
<br />M A Y� �H�{_ K� �}4'�'A�3L� 7'�: AE��{�H�L &�A[�$L�NG ENE�DFkCEMkrNT 1}I �' f���N
<br />. I���
<br />'�a��F��tF� ;t�+�if:�i 1 f rri.�-
<br />.��-f,-s3�� nf �:t� �tirri�+� � fa�c,�
<br />r�,'��-. E•�! �-1=�=i�i.'=_i5� �1!��}t9�i �t:r? P•°�i�
<br />'�ri : k'�•� L: i�. ��� c�� 1�•-��f�
<br />�'�rk�r� � ��i`� i� Esis C:u, _
<br />! C i I�rAC'o�inly whcre pe: rnis 3��p,na�:
<br />Fcemi� Namc:
<br />Ti:7J� ��:�r_�c�.
<br />Lo���i�kn a�drt �k:
<br />�'i�}�, �to�e. �[PCnd��
<br />[ia�•,,nKax F'�un�:
<br />I�f�2��TC
<br />�al i�y , I�.
<br />IP NAME AND ADDR�SS
<br />SHOWN ARE �i0'I �.��}��FC'T,
<br />MAK� CHANGES B�LOW
<br />Y�I ic} Pei'i�d _ _. _ — _
<br />I�4° s,�:�:i7� ik��s rc.�e�•a� ���pliLse;�,n� �f�.`JE��r.l �,:�rtifiy� Ihai lher� has b►xn n� 4..5aiy�� in uwnrash�i�., �+.arp�r.7l� �,F}i�Gn,
<br />���la,�wx, �nernl�r��i�p. �,r��iii��. hvenK �i�dres�ea. ar 6e€epL�one numbers. If chen�s ha� oceurrr..d �rriis� �Lio post L�
<br />>_n�i7dtis, plc��c grti�e dc�ai]� �m d� b�ck t,f Ghisr�n�wal� �k��n s�gn b�low,
<br />�oolicant�ssl�gt41�UI� [�9.]�Imew�ltontlrm�s ilre �irll�wr�in�= Fi�9lure �a oco�w[ �n� af thr Fal]o++�io� �•111 resuLt ifl �i�rs.
<br />I App�it�ani �4�f.-r�s L'�it i[ [��� ncvcr hsd � li�uor lic��se ��j�ciec� b�' 8ititi• �:ii3��SOw�$h���c;t,t�i7ip :�, sh� ��;���.+�r'
<br />Minr�sote_ lFcver ��cjcc�c�, plcssc gix�e �r,;i� n_� i h� ]�4� uf ih,s r��e+��nl. ilxn s;�a be6�,w
<br />?. App�oC�r�l ��mlirrns th�t fwifn� ps�€i fivc}+cars i[ hst� rio[ ��� s]eeju�r l�c�n&� 7�u;��d �4r �r•� Ji���r la++v Mi��a;=�a�7 ;�lai�
<br />u� iocaL�. If a rew��eai�on ]ia� c�c�rr�d, p]e�se gi++e �lel�ils uo Ih� back af thi� rerrewe�l, �hen si�n bela�w.
<br />?. �ppli�ant �onFrins �hes d�ri�s� d�c pa�� fi,r� yesrx i< <,r i�z �mP���; h��u� ��t �s�4� �il�d f�r,�n}� �iui] +�r �rimin,il
<br />ii��7¢r 1a7w �ri�lai"s�ns. If wE�L�iUu� ha4e axu�,-ed, �Y�� �14� �CI)11I.5 �n lr�k �I'lh��: �en�,�l, i��n sign bel�w
<br />�. .���pli�inl �aR�irms that V�'arlvcr� ��n7pcn�arlU� iR�i��� i8 I�I ��f�1 F�r LfaG FuLI Li�cnsG pGriai.
<br />�. �ppl��,�nk �n�t:r.ns. r�o clu� on�ale i�[oaicaiir�g liq�or Lirt�er�ea is hrld_
<br />u�pplic:in� t�r_F��y,{ buk���c�s �a�e��r_�� ��re sr.pa��ic from �r.}� nchGr bus�n�ss csWblisnn7cn'
<br />� +� ��
<br />Ap}11i�s�5L S ��n:�LLLT4_ �4'�'�'�`�i►����v���J� . _ __ L7,�'� � "� �
<br />�5ig�s���u� �r��firs al] abo+�e. inforn7a�ion aa t+c cqrr�ci ���d �r`rhi� 4�s he�n appruwed I,r1 �il�r�u4:in��� ]
<br />C'�L� �'I�ik�['t7pnl}r,�71{Ili4C �SJ€flBLUi{ — — �0.1G
<br />{ Si��tiasus� Ley ifieb thn' .i �onstimpii� �nd �i�a� �arr�pi� ]I�� �n :�FFr�,vo� bj' Ih� c:iij��[�ur�� .7s �:uicd Ybo+�r. )
<br />1�5C.+�.X�' rt:� I �7,ti};
<br />14rno�n! l�ecei��d
<br />
|