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Wilbur F. Dorn, Jr. August 27, 1946 <br />{Name) (Birtndate) <br /> <br /> 16610 Flourine St NW, Ramsey, MN <br /> <br />~d~ess) <br /> <br />Thomas W. Anderson <br /> <br />(Shareholder/Officer - Circle One) <br /> <br />March 10, 1942 <br /> <br />(Name) (Bizthdate) <br /> <br /> 16831 Helium St NW. Ramse_vo MN .. <br /> (Address) (Shareholder/Officer - Circle One) <br /> <br />(~ame) (Bit thdate) ' <br /> <br />(Ad. ess) <br /> <br />(Sha~eholde[/Officer - Circle One) <br /> <br />(Name) (Birthd~te) <br /> <br /> (Address) (Shareholdei/Officer - Circle One) " <br /> <br />3) Are each of the officers and/or shareholders named above citizens of <br /> <br />the United States? Yes <br /> <br />If no, state the circumstances for each officer/shareholder who is not a <br />ci~tzen. <br /> <br />If natunalLzed, state date and place of naturalization. <br /> <br />4) Give the full name and address of each officer's/shareholder's spouse. <br /> <br /> Officer/Shareholder Spouse Addr es s <br /> Wilbur F. Dorn, Jr. Jacqueline Ann Dom same as above <br /> <br />Thomas W. Anderson <br /> <br />Pau!a A. ~mderson <br /> <br />same as above <br /> <br />Page 2 of 8 <br /> <br /> <br />