Agenda - Council - 06/22/2004 - Laserfiche WebLink

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Form SP:Ci LiCENS£ APPT P~,~ lk'q~' Pursuant to Mi~'mesota Statute~,"70.7" Tax Clearance; issuance of Licenses. the licensing authont3, is required to provide to the Mirmesota ConmTissioner of Revenue yom' Mnmesota business tax identification number and the Social SecuriD' Number of' each license applicant· Under the Minnesota GovetTanent Data Practices Act and the Fedsral Privacy A.c~ of 1974, we are required to advise you of ti~e followina re~arding the use of this information: This information may be used to deny the issuance, renewal, or trans£er of your iJcense in the event you owe the Mim~esota Department of Revenue ddinquent taxes, penalties, or interest. 2. Upon receiving this information, the licensing authoriw, will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Deparm~ent of Revem~e may supply this information to the Internal Revenue Se~ice. 3. Failure to supply tlzis m£om2ation may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the foltowmg im%rmation and return along with your application to the agency issuing the license. DO NOT P,~ETUI'~N TO THE DEPARTMENT OF REVENUE. License Being applied for or renewed: Peddler/Solicitor/Transient Merchant License Licensing Authonu,: Cib, of Ramsey (Name of City, Coumy, or State Agency issuing License) License R. enewal Date: January 1,2005 PERSON.,-~L INFORMATION (il' applicable): Social Securm./Number: City Stare ZIP BUSINESS INFOtLMATION (il' applicable): Business Name: Business Address: Mnmesota Tax Identification No.: City State ZIP Federal Tax Identification No.: Lf a .,'vhm~esota Tax ldenufication mtmber ~s not required, please explain on the reverse side. Signature Position (Office,.', Parmer, etc.) /.)ate -10-