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

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Form SP:CI LICENSE APPLICANT: Pursuaut to Mim~esota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing attthority is required to provide to the Minnesota Conm~issioner of Revenue 7our Minnesota business tax identification number and the Social Security Number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Pr!yacy Act of 1974, we are required to advise you of the fbllowing regarding the use of this information: 1. This inIbrmation may be used to deny the issuance, renewal, or transfer of your license in the ex, ent you owe the Mim~esota Department of Revenue delinquent taxes, penalties, or interest. 2. Upon receiving this reformation, the licensing authority will supply it only to the Minnesota Depamnent of Revenue. However, under the Federal Exchange of information A~m'eement the Department of 1Kevenue may supply this information to the internal Revenue Se~wice. 3. Faiku'e to supply this intbtTnation 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 fbr or renewed: Peddler/Solicitor/Transient Merchant License Licensing Authoriw: City of Ramsey (Name of City, County, or State Agency issuing License) License Renewal Date: PERSONAL INFOI~VlATION (if applicable): January 1, 2005 Applicant's Name: Applica.nt's Address: Social Security Number: L-/ -7 ff - BUSINESS INFORMATION (il' applicable): Business NalTm: Business Address: City State Oci - ZIP City State Minnesota Tax Identification No.: Federal Tax [dentificatiou No.: If a iv[nme.sota Tax Identification number is not requn'ed, please explain on the reverse side. Signature Position (Offi~e~, Parmer, etc.) Date ZIP -85-