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APPLICATION/RENEWAL <br />AMUSEMENT CENTER LICENSE <br />Fee - $15.00 Per Site <br />AMUSEMENT DEVICE LICENSE <br />Fee - 515.00 Per Machine <br />L U~/~C~ ~~7 ~/~~C/ ~3-f2~~ -~'~'C <br />Trade Name <br />~~ <br />Number of~4fae~iaes <br />r~6 ~s- <br />License Period <br />~ib'i~r,t*~ ~ j o20c"i ~ <br />Date of A lication <br />yi-~'~s~~/9 <br />~~~. ~9a8 <br />MN Business ID No. <br />1. Type of Application: k New Renewal Transfer <br />z. ~l/~2r}~~ 6~ • ~~«6~/ G/~ ~ gam- o ~!a <br />Name of Applicant Phone <br />Home Address ity State <br />Date of Birth Social Security Number <br />5, r~ ~lOZ~ !~/c.c= ~ /T~?~ /yr~,F~fjd~G~ <br />Address of Business Location <br />E4'ss/iV ~~ ~.rL /~•~c~c~t~JA.4cS <br />6. List owners of~+ildiitg or premise to be licensed: /~/i / / <br />/ ~ '~ <br />7. <br />Corporate or Partnership Title <br />Corporate or Partnership Address <br />9. List all partners, officers or directors, if corporation: <br />Name <br />Address <br />~--~-~-.~;.:x~ <br />,~ <br />Date of Birth <br />~~!~-Y~ <br />a - ~ ,~ <br />10. If this is a transfer application, give name, address, persons, partnership or <br />corporation holding the license for the past year. <br />Page 24 <br />