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Form DPS9114-5-75 <br />M5 <br />STATE OF MINNESOTA <br />DEPARTMENT OF PUBLIC SAFETY <br />LIQUOR CONTROL DIRECTOR <br />APPLICATION FOR COUNTY OR CITY ON SALE WINE LICENSE <br />NOT TO EXCEED 14% OF ALCOHOL BY VOLUME <br />This application and the bond shall be submitted in duplicate. <br />Whoever shall knowingly and wilfully falsify the answers to the following questionnaire shall be deemed guilty of perjury and shall <br />be punished accordingly. <br />In answering the following questions "APPLICANTS" shall be governed as follows: For a Corporation one officer shall execute <br />this application for all officers, directors and stockholders. For a partnership one of the "APPLICANTS" shall execute this application <br />for all members of the partnership. <br />EVERY QUESTION MUST BE ANSWERED <br />as.5 i I•)C /L % �I �Tt?I'/ i F.�l�l /` /' <br />(Individual owner, offscer, or partner) <br />for and in behalf of ___ aj-1y- I / C�. 9 e 5 C t ��-��z ' 1 i r„� , hereby apply for an On Sale <br />Wine License to be located at "' ' i / -� <'.- 1 <br />(Post ffice Address) <br />County or City of ( I 't (a," i y <br />State of Minnesota, in accordance with the provisions of Minnesota Statutes, Chapter 340, commencing <br />l 9 , and ending <br />2. Give applicants' date of birth <br />Birthdates of Partners <br />or <br />Officers of Corporation <br />(Day) (Month) (Year) <br />(Day) (Month) (Year) -- <br />(Day) (Month) (Year) <br />(Day) <br />(Month) <br />3. The residence for each of the applicants named herein for the past five years is as follows: <br />(Year) <br />/ <br />4. Is the applicant a citizen of the United States" Yf' <br />If naturalized state (late and place of naturalization _ I4lF `/ - 5 r / rl_, 4 1, i� r'� f/i <br />If a corporation, or t)artnership, state citizenship status of all officers or partners. <br />S. The person who executes this application shall give wife's or husband' s full name and Clerk's exhibit no. <br />meeting 4-14-76 <br />