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C1ct 18 05 03:31p City of Falcon Heights 6516448f75 <br />p.4 <br />STATE ~JF N.~IY~3EBOTp TAB: D FDF.N <br />L?'CENSE ~~'PLSC1~tT 2N?~'oRltiA.TZaN <br />T:+z~der A~:.siaesatswaw (A4.5..~70. "^ ; , <br />the bY:;.su~esdtG ~a:naissi ,- ", thm agency iesuire you this 1:.censA i.s reat__ <br />5CC1.2,.1 B ~^ Dne,. d2 keveuue yauw u`inneSOta Dusi ' EC! O Dx"Ol^1C~; <br />~C'ix"..~~' rli1T.+JE'. O,x. ESC ~ 7.Q°_A9e appl1C21".t. tteSS t~3; 1C~".:1Zti'F1GatS.CZ cIId t~S <br />*.;nder the "^ ;ru,'SLx~.~Gavel~uu*.*~e~:t ata p's,ctlces Ac*_ and the ~edexal Privac r <br />Y A..t c_ lS?~r we <br />This i ~-. <br />.~a=-ratio. may be used to deny the issuance, renews'! ar tranEfer of ycur <br />license i= ou flw t e <br />Y e h~ A2:.s:~xedots Degartmerat o$ Revenue cielinrtueat taxes <br />penalties, or irteres.; <br />• T~woverensi:g agency ~~ill sus ~ . } , <br />~= sridsr ae ~`ederal Exc~iani ~ only to the Minnescta. D.part:nent of Feve.ue . <br />ie a:.lowed to supply t;ais ia.fcx~a~ion~te~ ~~t~a" Act, ohs i7epartment o Revere; <br />• p'aili.^zc tc supp ~ y this -r~+W :~x'iilat:iQ71 ~ In,.etZtB.~ Revenue 5sz-vi.e; <br />-.-sense or ~^^ocessing your r a may jaopAsdiza or delay t:7z issuarc= ci yo~sr <br />en..wai application. <br />Pisses f_li ir. the rollawiaa nforrnetic«: and ret~ <br />the ages~.c;~ :~asuis~g th` li=ease. Da zaot rett.~,.a tc the Depa_ msxstoo~ ~~~~~ yc~:r. app'xicatior. tc <br />~eVel.'tle . <br />f L <br />ivame cf Wicease toeing applies fdr aac <br />License nurn~er <br />~ ;please print or type) <br />- ~ t-~4" ~ L' P1e^v T1~i ~ ~e. <br />~ieensiw_ Autharicy iaame o~ city, unty, ox state a snc issuiaa yaen.se) <br />g y i.: <br />License renawal date <br />Persaxaal ia.fortua,tio~z; • <br />~'~,. ~ .. <br />?~pxlicant's last name <br />~a3o.S "i`. ~ .s Cn ~ ~'--~ <br />Applicant's address <br />ty <br />Busia~s~ ~rorm~tioc ;~f ~Pplicable) <br />8w.~ mess name ~~~ ~ ~ ~ -i- C_. ~~) / i v~1 <br />r <br />~susiness address <br />seats tax idsifiaatiac <br />r°- <br />'r ~ <br />_.: ts- <br />sS~"J /~ <br />a <br />Zip <br />~~ <br />tax idsatifica;.icx aster <br />?f a Minsasota .tax :~d.e_*sti~icati.aa nuaber is •not re <br />qu'red, please explain: <br />~ ® ~a - <br />S ~. gnn Lures <br />~~ ~~~ <br />--.--.r____ <br />~.+. E <br />Stu ~~- <br />• First assts & <br />L~~,~;-I~ t~~~~ l .~~~ <br /> <br />ri3 is E <br />Sts*_e <br />