Agenda - Council - 10/25/1994 - Laserfiche WebLink

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Form SP:C! ~ LICENSE APPL1CAb~T: Pursuant to Minnesot~ Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security Nfimber of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the fc~llowing regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event youiowe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue, However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service.; 3. Failure toisupply this information may jeopardize or delay the processing of your licensing issuance ot renewal application. Please supply the following inff~rmation and return along with your application to the agency issuing the license. DO NOT RE ~T~JRN TO THE DEPARTMENT OF REVENUE. LICENSE BEING APP.~IED FOR OR RENEWED: Pawnbroker / ~condhand Goods Dealer LICENSING AUTHOklTY: CiB, of Ram~,y (Name of City, Court'or State agency issuing license) LICENSE RENEWAL DATE: PERSONAL INFORM~ATION (if applicable):~ ~, //~/~ ;: - City ~z~ ~ - State ZlPCode Social Security Number: ~7~/~ ~" ~a:'t/r'' 7 / ~ 7 Business Name: ,/~,,~,,K. ,a~::?,,,a~ .~ ~' ~- Business Address: ?~7//~-~ ~ ~ ~° City State ZIP Code Minnesota Tax ]dentifi Federal Tax ldentificat on No.: '~/- / 5~'.,Z-, -' .~TdfY Ifa Minnes..~ax ldentif~l~ion number is not requi.~ase explain on the reverse side. gn Position (Officer, Partner, etc.) Da te