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STATE OF MINNESOTA TAX ID FORM <br />• <br /> <br /> <br />LICENSE A_'oPLICANT 2N~'ORMATION <br />tinder Minnesota law (M.5.270.72), the agency issuing you this license is required to provide <br />the Minnesota Commissioner of Revenue your Minnesota business tax identification and the <br />Social Security number of each licease applicant. <br />tinder the Minnesota Government Data Practices Act and the Federal Privacy Act of 197?, we <br />must advise you that: <br />• This information may be used to dewy the issuance, renewal or transfer of your <br />licease if you owe the Minnesota Department .of Revenue delinquent taxes, <br />penalties, or interest; <br />• The licensing agency will supply it Daly to the Minnesota Department of Revenue. <br />However, under the Federal Exchange in Information Act, the Department. of Revenu <br />is allowed to supply phis information to the Internal Revenue Service; <br />• Failing to supply this information may jeopardize or delay the issuance of your <br />• .licease or processing your renewal application. <br />Please fill ia'the f ollnwiag information sad return this form along with your app~licatioa to <br />the agency issuing the licease, Do not return to the Department of Revenue. <br />icease <br />Licensing Av.thox'ity (acme <br />License renewal date <br />Personal information: <br />I ie <br />Applicant' last name. <br />Applicant's address <br />d <br />~G~ <br />ity <br />Business 2aformatioa (if applicable) <br />~~~~ <br />.eusiness name <br />,!7 ,~' <br />Business add ess , <br />Minnesota tax ideat <br />amity <br />cation number <br />tax <br />?$ a Minnesota.tax identification number is•aot required, please eacplaia: <br />Date <br />for sad license cumber <br />print or type} <br />~~~y, ~~~Ly, or state agency <br />r '-[~'/' <br />came & <br />~-l ^ <br />to <br />social s <br />urity avsnber <br />l3ll <br />State <br />Code <br />oa number <br />