Agenda - Council - 10/11/1988 - Laserfiche WebLink

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LICENSE APPW~CANT: Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is re~uired to provide to the Minnesota Co~lssioner 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 aOvise you of the following regarding the use of this information: This Information may be used to Oeny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or Interest; Upon receiving this Information, the licensing authority wtiI supply It only to the Minnesota. Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue m~y supply this Information to the Internal Revenue Service; Failure to supply this Information may Jeopardize or delay the processing of your licensing tnsuance or renewal application. Please suably the following information and return along with your a~a}fcation to the agency Issuing the'license. DO NOT RETURN TO THE LICENSE BEING APPLIED FOR OR RENEWED: (~)' ([1'9~C~'.(j~ ~..t?C~, t~illt~ LICENSING AUTHORITY: (name of city, county or state agency issuing license) LtC[NS DATE: I--I PERSONAL iNFORMATION (iF a~¢~llc~ble): A~)icant's Name: Appltcant' s Address: / City S~cial Security Number: ~ BUSINESS INF~HATi~ (if ~li~le): Business Name: . .,-'~ Business Aoaress: ~ ? /0 H~nnesota T~x IdenciFicetion Federal Tax ]dentificetion State Zip C~oe State Zim Code if a Minnesota Tax Ioentification number Is not re. muired, please ex2lain on ~he reverse side. " Signature ' ' Position (OFFicer, Partner. etc.) Da~e