Agenda - Council - 07/23/1991 - Laserfiche WebLink

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Form SP:C1 LICENSE APPLICANT: Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnc~oota business tax identification number and the Social Security Number 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 following 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 you owe 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 to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following information and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. LICENSE BEING APPLIED FOR OR RENEWED: LICENSING AUTHORITY: (Name of City, County or State agency issuing license) LICENSE RENEWAL DATE: PERSONAL INFORMATION (if applicable): Applicant's Name: Applicant's Address: Garba_ge & Refuse Hauler qi~ of Ramsey ]avuo .ry 1,1992 City State ZIP Code Social Security Number: BUSINESS INFORMATION (if applicable): Business Name: City State Minnesota Tax Identification No.: Federal Tax Identification No.: ZIP Code If a Minnesota Tax Identification number is not required, please explain on the reverse side. . Sig at ~e 0 .... (~ '-~Position (Officer, Partner, etc.) Date