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of L~censes, <br />pursuant %0 ~innesc%a ~' ~ * 270.72 ~ax Clearance; Issuance <br />the licensing authority Js required to provlOe ~o ~ne ~innesosa <br />C~lsstoner oF Revenue your Minnesota bus~ne~s tax Identification number <br />anO the social security number of each license applicant. <br />UnOer the Minnesota Government Data Practices Act and the Federal Privacy <br />Ac~ c~f tg?4. we are requ~re~ to aovise you of the following regarding the <br />use or ~h~ information: <br /> This Infor~tfon n~y be used to oeny the Itsuance, renewal or <br /> transfer oF your license in tha event you owe the ~lnnesOta <br /> Department oF Revenue oelinquent taxes, penalties or Interest; <br /> ~. Upon receiving this Infor..~tlon, the licensing autnorlty will <br /> supply It only to the M~nneso~a. Department of Revenue. However, <br /> under the Federal Exchange oF lnfor~tion Agreement the <br /> Demartment oF Revenue m~y supply this In~orm~tton to the lnterna~ <br /> ~even~e Service; <br /> F~liure to su~ly this Infor~tlon ~Y ~eom~rOtze or oelay ~he <br /> pFoce~tng oF your licensing insuance or renewal ~mmlic~tion. <br /> Ple~e sum~ly the Fo~lowin~ inFor~tion and return alon~ wi~h your <br /> ~mllc~ion to the ~ency I~su no ~ne l~cense. ~ ~T RETURN TO THE <br /> <br /> L~CERSE BEING APPLIED FOR OR R~N.~D. , ~ <br /> <br /> ~name of city, county or staze agency issuing~license)~_~ <br /> LICENSE.RENEWAL DATE: <br /> <br />PERSONAL INFORMATION (if a~piica~le): <br /> <br />A=plicant's Name: ~-~ ~ J <br /> / <br />A=olican~'s Actress: <br /> <br />$::ial Se:urity NumDer: m~S / -~ <br />B~SINESS INF~HATI~ (~f <br /> <br />Zip Code <br /> <br /> City 5~ate Zip Cooe <br />,~,innescta Tax identification NO.: ~. ~,, <br /> Tax Identification No.: <br /> <br /> <br />