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STATE OF M=NNESOTA TAX ID FOp.M <br />• LICENSE A_'oPLICANT INFO??MnTION <br />Under Minnesota law (M.5.270.72), the agency issuing you this licease is required to provin: <br />the Minnesota Commissioner of Revenue your Minnesota business tax identification and the <br />Social Security number of each licease applicant. <br />Under 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 deny 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 only to the Minnesota Department of Revenue. <br />However, wader the Federal Exchange is Information Act, the Department of Reveni <br />is allowed to supply this 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 ir_' the following inforrsation and xe"„-, this form aloes with , <br />the agea.cy issuing the licease. Do not return to the Department of Reveaue~ application to <br />Tr ~' ~ ( (M, I'll t (il e K C. K <br />Name of licease being appli for and lic a number ~ ~ V;~ ~ S <br />(please p t or type) <br />Lzceasing Authorit (same of city, county, or state agency issuing licease) <br />.License renewal date <br />Personal iaformation:~ <br />• <br />Applicant's last name. First same & initial <br />social security number <br />Applicant's address City State <br />Zip Code <br />Business Saforma,tioa (if applicable) : <br />Business name <br />Bus <br />7~~~~~ <br />ota tax ideatifi <br />ty <br />sium~er <br />State <br />/.-~ ~ r <br />7Z <br />tax identification a <br />?f a Minnesota.tax identification number is•aot required, please explain; <br />t1e <br />~~_ <br />Date <br />/ , <br />J <br />