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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1-500- 552 -0013. OR (6 222 -0484 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written rejection, current license, and <br />required documentation of liquor receipts are not attached. Coverage cannot be bound prior to 12:01 <br />ant the day following receipt of the above by the Administrator_ <br />Legal Name of Applicant / "We (� CEN.GICt6? C /?o 71?4 ✓t 4sYOc . <br />Trade Name <br />Mailing Address 3I .s t; AXe (Q .7 4614 V t( • , nA✓ a S (1 <br />Individual Partnership _Corporation X Non - Profit ._,Other <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership or Corporation: <br />Name of Each Farmer or Owner Percentage of Ownership <br />Operating Location(s) — List all Locations: <br />1, Old t ji-? (c,- tent,:, Fire Lint( 2. <br />Classification <br />Primary Nature of Business: tref i S i pi) <br />Check all applicable. <br />I. __.Restaurant 2. Club 3. Bar <br />4. _Bowling Alley 5, On/Off Sales 6. Off Sale Only <br />7. x Special Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity Total Bar Only <br />License in Effect? _Yes No <br />Licensing Authority <br />Address <br />License Number <br />Effective Date Expiration Date <br />License Ever Revoked/Suspended? Yes ! No If yes, date <br />ri yes, explain <br />