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11. What vending or mechanical amusement device company has or will have <br />machines on the licensed premises? <br />'~~ <br />12. List numbers and <br />~d <br />13. Are you a Minnesota resident? <br />If not, where resident? <br />Yes No <br />14. Applicant and his associates in this application will strictly comply with the laws <br />of the State of Minnesota and all City Ordinances; and hereby certify that <br />applicant has read the foregoing questions and that the answers to said questions <br />are true of his/her own knowledge. <br />I understand that the information provided in this application may be considered private <br />or confidential data. I further understand that I may not be required by law to provide <br />such information. The purpose of providing such information is to aid the City in its <br />determination on my application for an amusement device license. I acknowledge that <br />providing, or failing to provide, such information may affect the City's determination of <br />my application. I understand this information will be made available to the City of Little <br />Canada, its City Council, agenda and representatives, as well as the Minnesota <br />Department of Revenue, or any other person or entity authorized by law to receive said <br />information. I release the City of Little Canada from any and all liability for its receipt <br />and use of data received pursuant to this apptic~on. ~ N ~ ~ ~,~ <br />Signature of Applicant / / <br />Subscribed and sworn to b fore me this <br />~~d y o 2000. <br />• ~~ <br />Notary Public ~ ~ <br />.... <br />4'ATNI CHfi7 A. G~_AN7FR <br />~. <br />of machines located on the licensed premises: <br />L , ,~- Ll, r,~2.~L- ~- <br />' KATHLEEN A GIANZER <br />NOTARY PUBLIC~MINNESOTA <br />MY OOMMISSION <br />'.«u' EXPIRES JAN. 31, 20105 <br />Page 26 <br />