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OCT 19 2005 11:24 HP LRSERJET 3200 P,3 <br />Oct t6 -OS 03: 53p - Ci t~ of Fal can Hari ~F-ts 6516448675 p. 3 <br />_ STATE a~ MZ'i~N'ESOTA TAB 2D i~ofrM <br />LTCffi~T5$ APPLICANT INFORDQAT=ON <br />Vnder Minnesota law {rr,s,a70,72?, the agency :.sAUing ypu this licanta ie rea_uired to provide <br />the Miaacsota Camnissitmtr of Revenue yatxr Mumesota busiaaas tau. ie~atifieatioa and the . <br />social Betzurity autabez of each liesaee applicant. <br />Danes--tk~~ts-Oages°stmeat Deis Prtetices Act sad the Pedrral PrstiacyAOt: or" rs7l, t+rE <br />moat et3t-ise you that: <br />~ Thin -fII~C3'!L&t:lOII ffiEy bL i3~$$ tP dP.IIy the ~R1U8IIIIl. 2'6II@6"'a~ Or' tt83IS:t~ Of" p'01s <br />liceASe it y011 Dort the MianasOta Department .o# Revenue cieli.a~~Tt taxes, <br />psualtiea, or interest; <br />• The licensing aganoy pill supply it canly to the Mianeaot;a Departtneat of Rtvtaue. <br />8oorover, wader the Federal P~cahaage is Issfosmatioa Act, the Deparemer~i of Revenu <br />is allowed- to augply .this iafoamatioa tc tht taternal Re~veaue- servieer <br />• Failing to supply this infozrnation map jeopardiat ar del my the ieauance of yovs <br />.license or proctgsing your xrsteval application. <br />Pleas' fill ia' tht fcllatoisse iafartt>etion and sttuta this torte along uZth your application to <br />the .ageaay e1Q~_ .the. lioaas4~ . Dn nat. rer,+,~• tp the <br />RaFartmeat of 1;i_evenua, <br />Peraoa,al information: <br />Applica'nt's last same. First aavtn & initial ^oa.a3 sadurity ac+a>bar <br />$pplicaat's address City State ~ Zip Code <br />Sstcj.aaa~ t,if- apgal._nabi4~ . . <br />a aa+ne <br />`1~~ ice, nn~-f~kR.1`~t~e. K.1• ~(~, `~' I~+~~wk4- ~ lli ~`CS~3'7 <br />Bus ea address City state - Zip Code <br />D6saaosota. tax it3aatiiicatiea aambar Sradatal t,ax idtatitication atmber <br />_¢ a 1Q3.naasota .tax i9aatitioatioa ataber is ~uot Xaguirad, plans saepl~~iae <br />