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

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~C[NSE APPLICANT: Pursuant to Minnesota Statute 27D.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provIoe to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. UnOer the Minnesota Government Data Practices Act eno the Federal Privacy Act of 1974, we are required to aOvise you of the Following regarOing 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 Deoartment of Revenue oelinquent taxes, penalties or interest; Upon receiving this Information, the licensing authority will supply (t 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; Failure to supply this Information may Jeopardize or delay the processing of your licensing insuance or renewal amplication. Pleese supply the following information and return along with your aoplfcation to the agency issuing the license. DO NOT RETURN TO THE DEP^RTME.T REV UE. LICENSE BEING APPLIED FOR OR RENEWED: ~Dq LC~---j~F~iO1Ctt-~ LICENSING AUTHORITY: C.i(~T~[ (name oF city, county or state agency issuing lffcense},,~__ PERSONAL INFORMATION (if al~pllcaDle): APPlicant's Name: ?)~z/ ~- Applicant's Aooress: City Scare Zi~ Coae Social Security Number: BUSINESS INFORMATION (if ~lica.ble): Business ~me: ~(~ i~' P S o ~ Buslness ACtress: ~ '7/ /0 Minnesota Tax Identification NO.: Federal Tax Identificetion No.: City State Zio Co~e if a Minnesota Tax ]oentification number is no'; re.=uireO, please explain. on ;he reverse s iOe. Signature ' ' Posi~ion (Officer, P'ar~ner. e~c.) Da~e