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<br />LICENSE APPLICANT: <br /> <br />pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses. <br />the licensing authority Is reQuired to provloe to the Minnesota <br />Commissioner of Revenue your Minnesota busIness taX Identification number <br />and the social security number of each license applIcant. <br /> <br />Under the Minnesota Government Data Practices Act ano the Federal Privacy <br />Act of 197~. we are reQuired to advise you of the following regarding the <br />use of thi s informat ion: <br /> <br />1. This Information may be used to oeny the issuance. renewal or <br />transfer of your license in the event you owe the Minnesota <br />Department of Revenue oellnQuent taxes, penalties or interest; <br />Z. Upon receiving this information. the licensing authority will <br />supply It only to the Minnesota, Department of Revenue. However, <br />under the Feoeral Exchange of Information A9reement the <br />Department of Revenue may supply this Information to the' Internal <br />Revenue Service; <br />3. failure to supply this information may jeopa~dl=e or delay the <br />processing of your licensing Insuance or renewal BPpllcation. <br /> <br />Please supply the following information and return along with your <br />BPpllcationto the agency Issuing the license. 00 NOT RETURN TO THE <br />OEPARTMENT Of REVENUE. <br /> <br />LICENSE BEING APPLIED FOR OR RENEWED: <br /> <br />~~I Ll1f j 0ur1reHe J Bi /.110.)(& 1d..!:1 e <br />.J <br />(j :, . ,.f' 0t <br />Un~ tt I 11'Si? ( J <br />issuing.)license) I :J <br />1- -69 <br /> <br />LICENSING AUTHORITY: <br />(name of city. county or state agency <br />LICENSE REN~~AL DATE: <br /> <br />PERSONAL INFORMATION (ff applfcable): <br />0- 9~ ~ r' J~ A 11; P h P J;: / +' r <br />/<( 9 ~? f ~/ ;::-ro.. n <br />, pf 0,-- rn s C, /J; /z/ <br />City S~ate <br />Social Security Numt:>er: ~ J?"'" =? c/ - (,;> C/ .5 / <br />BUSINESS INFORKATION (if applicable): <br />. Business Name: (l L( e. -r;- /}.1 p ^' /// ',,-: J- c/c: <br />Business Address: .J"f: c./.e rC; ~../7d ~~:z:.'# <br />kA rns,e7 . yJ7~ ,_~S:--5 0 .~ <br />City S~ate Zip Cooe <br />Minnesota Tax I den": Ifi cat i on No.: /? c r ~P'P:?/~\? d ..;: 'y" <br /> <br />Apolicant's Name: <br /> <br />Applicant's Address: <br /> <br />c I"~ .f? IlJe::! <br />S-S-?5 0 =? <br /> <br />Zip Cooe <br /> <br />Federal Tax Identification No.: <br />If a Minnesota Tax Identification numt:>er is not r€ouireo. please exolain. <br />on the reverse sioe. <br /> <br />Signature <br /> <br />Position <pfficer. Par~ner. etc.) <br /> <br />Date <br /> <br />2-D <br />