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STATE OF MINNESOTA DPS 9136 (10.75) <br />DEPARTMENT OF PUBLIC SAFETY <br />,*4M1V1 LIQUOR CONTROL DIVISION <br />APPLICATION FOR OFF SALE INTOXICATING LIQUOR LICENSE <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 <br />deemed guilty of perjury and shall be punished accordingly. <br />In answering the following questions "APPLICANTS" shall be governed as follows: For a Corpora- <br />tion one officer shall execute this application for all officers, directors and stockholders. For a partnership <br />one of the "APPLICANTS" shall execute this application for all members of the partnership. <br />EVERY QUESTION MUST BE ANSWERED. <br />BUSINESS APPLICANT'S HOME <br />PHONE NUMBER _ 41r -C4 4(In - _ PHONE NUMBER <br />1. I ON I rc, 11i7e. E!CyI-)I as C'- <br />(Individual owner, othcer. or partner) <br />for and in behalf of f C t*` �-' q t't b `' i -- - vi c, • , hereby apply for an Off Sale <br />Intoxicating Liquor License to be located at Z t' �' �{ �'`-' !%' `:.► j �(N, <br />br (S(reet Address and/or Lot and Block Number) <br />Municipality of L . +--t le, Cei r iet deL _ County of_ <br />1 <br />State of Minnesota, in accordance with the provisions of Minnesota Statutes, Chapter 340, commencing <br />7•— / , <br />1976-, and ending77 <br />�r Give applicants' date of birth <br />(Day) <br />(Month) <br />f Year) <br />Birthdates of Partners <br />(Day) <br />(,'Month) <br />(Year) <br />or <br />(Day) <br />(Month) <br />— <br />(Year) <br />Officers of Corporation <br />(Day) <br />(Month) <br />(Year) <br />3. The residence for each of the applicants named herein for the <br />past five years is as follows: <br />4. Is the applicant a citizen of the United States? <br />If naturalized state date and place of naturalization — <br />If a corporation, or partnership, state citizenship status of all officers or partners. <br />hOth q f.f: Q I. I ; Z—t. G, S <br />5. The person who executes this application shall give wife's or husband's full name and address <br />C 7 - Ati -S "►' �� �r t � �� t1 t - I e, L. <br />6. What occupations have applicant and associates in this application followed for the past five years? <br />C 14 c, - r- t t; y'r C <br />If a partnership, state name and address of each member of partners} <br />Clerk's exhibit no.��� <br />meeting 4-14-76 <br />