Agenda - Council - 08/10/2004 - Laserfiche WebLink

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Form SP:CI LICENSE AP?LICANT: Pursuant to Mflmesora Stat-ute ,, 0.,: Tax Clearance; Issuance of Licenses. the licensing authonw is required to provide to ti~e Mi~mesora Commissioner of Revenue your Minnesota business tax identification number and the Socia! Seem'ltv Number of each license applicant. Under the Minnesota Govenmmnt Data Practices Act and the Federal Priyacy Act of 1974, we ar[ requh'ed to advise you of the following regarding the use of this information: .. l. This informauon may be used to deny the issuance, renewal, or n'ansfer of your license in the event you owe the Mirmesota 1Deparmaenr of Revenue delinquent taxes, penait~es, or interest. 2. Upon receiving this information, the licensing authority will supply it only to the Mirmesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Deparmaent of Revenue may supply tins information to the Internal Revenue Service. 3. Fa/inre to supply this informanon may jeopardize or delay the processing of your licensing issuance or rene~val application. Please supply the following information and return along With your application to r_he agency issuing the license. DO NOT RETUP,2N TO THE DEPARTMENT OF RE'~E-NUE. License Being applied for or renewed: Peddler/Solicitor/Transient Merchant License Licensing .~.utborJty: (Name of City, Count,.,,, or Stare Agency issuing License) City of Ramsey License Renewal Date: January 1_, 2005 · PERSONAL INFOlrLadATION (il' applicable): Ft State ZIP Social Securi~, Number: BUSINESS INFOI',U"t'IATiOb,~ (il' applicable): Business Name: Business A. ddress: Mim'~esota Tax Identification No.: Federal Tax Identification No.: State ZIP If a lv[im~4oFa Tax identificanon nun-tber is not required.' please exnlain on the reverse side ~/ ~ ~'l~'~ i~ ~'~'J/~ '/' ' ' ' SignOre ~' ' Positien (Officer, Parmer, e~) ' Date