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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1- 800 -552 -0013 OR (612) 222 -0484 <br />APPLICATION FOR LIQUOR L.I.ABILITY 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 the above by the <br />Administrator. <br />Legal Name of Applicant <br />Trade Name / L ' I`- . A <br />Mailing Address C/5- i.-= 7 F'k C1.. a,, La /;rt!- L Wr >Y/t7 <br />_Individual _Partnership _Corporation _Non- Profit < Other — <br />If Applicant is Individual: <br />Applicant Name N /rl Snouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />Operating Location(s) - List all Locations: <br />1. -1,-, < 2. <br />Classification <br />Primary Nature of 3usiness: <br />Check all applicable. <br />1. _Restaurant 2. Club 3. _Bar <br />4. Bowling alley 5. On /off Sales <br />6. _Off Sale Only 7. )(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 • <br />Address ( j <br />License Number <br />Effective Date i Expiration Date <br />License Ever RevoicedtSuspended? Yes No If yes, date <br />if yes, explain <br />PAGE 22 <br />