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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />18FUNt,;_,ii LAY 17u0 <br />ST. PAUL, MN 55101 <br />1 -500- 552 -0013. OR (6 -t2)- 222 -0484 <br />wtl <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 />a.m. the day following receipt of the above by the Administrator. <br />Legal Name of Applicant L; �L! (Citl C ci g-(62ect 176 rn % 55 o C , <br />Trade Name <br />Mailing Address 1.5- <br />2;016 Ccirw-4 fI <br />I c. , 551/7 <br />Individual Partnership _._Corporation 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 Partner or Owner Percentage of Ownership <br />Operating Location(s) — List all Locations: <br />n 5 )),C ��rr <br />Classification <br />Primary Nature of Business: Rfd ,Nell gW;, <br />2. <br />Check all applicable. <br />1. Restaurant 2 Club 3. Bar <br />4. _Bowling Alley 5. _On/Off Sales 6. _Off Sale Only <br />7. XSpecial Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above '/co 'CU <br />Seating rapacity 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 />If yes, explain <br />