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<br />FQnn SP:CI <br />LICENSE APPLICANT: <br /> <br />Pl,IfSUant to MinnclIOla ~tatute 270.72 Tax Clcllrance; ISlIuam:e of Licensea, the Iiclmlling authority ill required to provide to <br />the Minn.esota CommiSllioner of Revenuo your Minnesota business tax identification number and the Social Security Number <br />of each llcense applicant. <br /> <br />Under the Minnesota Government Data Practices Act llnd the Federal Privacy Act of 1974, we are required to advise ,You of <br />the following regarding the use of this information: <br /> <br />I. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the <br />Minnesota Department of Revenue delinquent taxes, penalties, or interest. , <br />2. Upon receiving this information, the licensing authority wi1\ supply it only to the Minnesota Department of Revenue. <br />However, under the Federal Exchange of Infc;mnation Agreement the Department of Revenue may supply this <br />information to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal <br />application. <br /> <br />" <br />Please supply the following information and return along with your application to the agency issuing the license. DO NOT <br />RETURN TO THE DEPARTMENT OF REVENUE. ' <br /> <br />Lice~se being applied for or renewed: Temporary Special Events Permit <br /> <br />Licensin~ Authority: City of Ramsey <br />(NamQ of City, CQunty, Qr $llIte Agency isauins Lloonse) <br /> <br />PERSONAL INFORMATION (if ~ppl1ellblll): <br /> <br />Applicant's Name: <br />Applicant's Address: <br /> <br />pltT'l./ c i i4 Pr,,~ Y /f1Y~ <br />q()I\~ ,3...;"'~ S+: u..J. <br />St-. Lou/s PL I11IV <br />City State <br /> <br />.0:.5"'1 til (; <br />ZIP <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION (if.appneable): <br />Business Name; , <br /> <br />H;crh <br /> <br />Sc II CJ() L /If a allla i1 h;.s;; e~ 1... (.. 1-. I! <br />I <br /> <br />Business Address; <br /> <br />7 b () 0 rOil T 1..A- tV i.) I). V J). <br /> <br />J< /, 11 flt~0 /J11V <br />City State <br /> <br />,5~~M '" J G, <br />ZIP <br /> <br />Minnesota Tax Identification No.: <br /> <br />Fedeml Tax IdenUfication No.: <br />If a Minne <br /> <br />Signature <br /> <br />