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Rug 08 05 O7:41a City of Falcon Heights 6516448675 <br />p.4 <br />STATE OR M2NN~50TA T.i,1,~ ID ?~pRM <br />• LIC~IITSE A~'PLICp,,NT INFOR~ATIQN <br />Hader Mirzaescta law _ <br />the Minnesota Co (M•5 270.72), the a <br />social sue" mmissioaer of Revenue 9'eacy issuing you this tic <br />cur_ty number of each liceaseya pl caatsota busi ease is '-"eL3uired to provide <br />aces fah identification and t;ae <br />L~aderadvise~esata Government Data Practices Act <br />must you what. <br />and 'the Federal ?rivacy Act of 1974, we <br />This information may be used to deny the issuance <br />. license if You. awe t}~,e <br />~ P~alties, or iaterest;~~esota Departmeat.of Reveaueed~e~,or tz'aasfer of yp~ <br />The licesis,iag agency will su _ 1 ~9ueat taxes, <br />However, under the Federal ~ Y It °~Y tD the Miane <br />. is allowed to au Exchange is Iafe iota Department of Rev <br />F'ailin pP1Y this information rmati°n Act, the Department of eaue. <br />g to supply this iaformatica to the Internal Revenue Bt Reveau <br />• ,license or pracessiag Your r may ~eDpardize or dale rvice.~ <br />enewal application. 1' the issuance of your <br />Please fill in' the f ollotoiag ; TTo,.~tioa and rat <br />'~~ agency issuing the license, Do not return to ~ Ds farm along with Your spplieatioa to <br />apartment of Revenue. <br />Name of lieease~beiag applied for ~ . <br />and license number <br />. (please print or tyre) <br />Licensing Authority (acme of city, couatY, or state s <br />goy issuing license) <br />. License rea,ewal date • <br />Persaas.]. ia~atznatiou: • <br />Applicant's" last mane ~ ~ <br />First aatae &~; tial <br />~ rs ~~ yr ~~ soainl eQCUrity sst:mber " <br />APPlicant's address w <br />City ~ ~ ~ <br />Btate Zip Code <br />$usia.~s$ =arormatioa ~. <br />~ {-'' ~. ~- It v~ -tv ~. ~~ ~ :~ <br />~usiaess same <br />.eeota tax <br /> <br />~ ~e <br />ty <br />n'tuoasr <br />state <br />~ ~~~ <br />decal tab i~ <br />?= a ~aa.esota,tax ideatifiaatioa number is•act required, please explain: <br />s ~~~ <br />ca <br />~~ <br />,t1e <br />-~ ..~~ <br />Date <br />• <br />