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Form SP:CI <br />LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the <br />Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security Number of each <br />license applicant. <br />Under the Minnesota Government Data Practice Act and the Federal Privacy Act of 1974, we are required to advise you of the <br />following regarding the use of this information: <br />1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota <br />Department of Revenue delinquent taxes, penalties, or interest. <br />2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, <br />under the Federal Exchange of Information Agreement the Depaiti ent of Revenue may supply this information to the Internal <br />Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. <br />Please supply the following information and return along with your application to the agency issuing the license. DO NOT RETURN <br />TO THE DEPARTMENT OF REVENUE. <br />License being applied for or renewed: Peddler/Solicitor/Transient Merchant License <br />Licensing Authority: City of Ramsey <br />(Name of City, County, or State Agency issuing License) <br />,fJ <br />License Renewal Date: January 1, (6 i» f 11 <br />PERSONAL INFORMATION (if applicable): �� <br />Applicant's Name: 4-0-0 vt. <br />Applicant's Address: ` C1 <br />�-7 �s �.� c-t U^ Ci �` `[C��� Pc-v 5 <br />City State <br />Social Security Number: <br />BUSINESS INFORMATION (if applicable): <br />Business Name: /a,e S-�c vl j �$ S [ <br />[ <br />veLi tQ <br />755�� <br />ZIP <br />Business Address: <br />Pc, <br />Minnesota Tax Identification No.: <br />Federal Tax Identification No.: <br />If a Minnesox&x Ide <br />Signature <br />l �S7 <br />/ City <br />State ZIP <br />111111111111111111, <br />icatio • i b(not required, please explain on the reverse side. <br />(.)2C /(), <br />Position (Officer, Partner, etc.) Date <br />Our Mission: To work together to responsibly grow our community, and to provide quality, cost-effective, and efficient government services <br />