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MINNESOTA JOINT UNDERw,RITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1.800- 552 -0013 OR (651) 222 -0434 <br />FAX: (551) 222'7324 <br />APPLICATION FOR LIQUOR LIABILITY CovERAGE <br />Coverage will not be bound if the correct premium payment, written <br />rejection, current license and required documentation of liquor <br />receipts are not attached. Coverage cannot be bound prior to <br />12:01 a.m. the day following receipt of e above by the <br />Administrator. /� ! <br />Legal Name of Applicant 7- 4L ((t1 6 61. �CC�QQfl nxdC <br />Trade Name <br />Mailing Address <br />S i S E. L --4(.e G h cl w 0 Lc, vtih/ 5-s--117 <br />®Individual _Partnership Corporation xNon-Profit Other <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />mew <br />Operating Locations) - List all Locations: <br />1. , old O +E cmnud4 Puct4,c,i( 2. - ery cy(.3 C ?1 &QcK ijl eo( <br />Classification <br />Primary Nature of Business: J vic / r a t S e ✓1 j <br />Check all applicable, <br />1. Restaurant 2. Club <br />4. Bowling ally 3. Bar <br />g Y 5. �`on /Off Sales <br />6. Off Sale Only 7. X Special Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity <br />Total Bar Only <br />License in Effect? Yes No <br />Licensing Authority Address <br />License Number <br />Effective Date Expiration Date <br />License Ever Revoked /Suspended? Yos Na If yes, date <br />If yes, explain <br />3 <br />