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STATE p~` MINNESpTA T_~,', ID FORM <br />• <br />• <br />LICENSE A_'oPLICANT INFpRMP_TIpN <br />Under Minnnesota law (M.5.270.^2), the agency issuing you this license is required to provid <br />the Minnesota Commissioner o= Revenue your Minnesota business tax identification and the <br />Social 5 ecurity number of each license applicant. <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />must advise you that: <br />• This information may be used to dewy the issuance, renewal er trans=er of your <br />license if you owe the Minnesota Department .of Revenue deliaq_ueat 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 Revea~ <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 />.license or processing your renewal application. <br />Please f i11 is the f ollav,*iag irs ormation and return this form along with your app~licatioa to <br />the agency issuing the license. Do not return to the Depa_Ytmeut of Revenue. <br />~-: n 31 .. <br />Name of license being applied for cad license <br />lease print or type) <br />~Xc..:l~ ~ l~l.' G h t'f~ 55~/Y °'1'ti°4c..~-t ~ ~.Y ~~~~ <br />uic.cns~.ug .erutnora.Ly ~aame o~ ~ci~y, county, or sate agency issuing license) <br />License x-enewal dame <br />Personal iafarmatioa: <br />ice` ~ "~ `~"( ~-. • <br />Applicant's last ~me.y zrst nam~& initial social security number <br />cant's address <br />Ci <br />Bv.siaess Ia.forxnatioa (if applicable) <br />to <br />Co <br />Business name <br />C~ <br />Business address Cit State Zip Code <br />Msaaeaota tai. ~,deatuicaLioa cumber ~'eaera.~ tar ideatificatiea number <br />If a Minnesota ,tax ideatificatiea number is •r~.ot required, please e~.-olaia: <br />lure: Title <br />Date <br /> <br />