Agenda - Council - 07/13/2004 - Laserfiche WebLink

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Form SP:CI 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 Minnesota 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 tbllowing regarding the use of this information: I. 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: (Nmne of City, County, or State Agency~issuing Mcense) License Renewal Date: Peddler/Solicitor/Transient Memha~¢~Acense City of Ramsey PERSONAL INFORMATION (if applicable): Applicant's Name: (~.A~ /-k~i4~ NI E I.% Applicant's Address: '3.-30 ¢,3 t~,[~q~.r_z,~,,~,w% Ak./--~ ? ~33x~-~: 2-1 3 City State ZIP Social Security Number: BUSINESS INFORMATION (if applicable): Business Name: Business Address: Minnesota Tax ldentificatiofi No.: State ZIP Federal Tax Identification No.: If a Minnesota Tax Identification number is not required, please explain on the reverse side. /o .,).-~:.-,? ~--' -- -'&--a'// ..Tz, v/4,"/" Signature Position (Officer, Parmer, etc.) Date