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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 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 the above by the <br />Administrator. ,{{ / �j <br />Legal Name of Applicant kj,7T% £LL/32.4'2 .L?2at/(/n. h'SS0 <br />Trade Name <br />Mailing Address <br />5/5 E. .G,1e_. ea nnda.. 'o 2.e S 5 /I 2 <br />Individual _Partnership Corporation ✓Non- 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 />Operating Location(s) - List all Locations: <br />1. t ♦� u' , • % 2. <br />Classification c y �cuTh n "C <br />4o /aS Primary Nature of Business: hd,e c , rk5I <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 `h'�(/0 <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity Total Bar Only <br />License in Effect? Yes No /� <br />Licensing Authority ent--a, o f 1,, ( 2na.c%4 <br />Address si s E. 4/#4.- „ Co ngc/a. k . tt in') 3SH 7 <br />License Number <br />Effective Date /0- 9,8l. 00 Expiration Date /0-07Y.O0 <br />License Ever Revoked /Suspended? Yes a'.t No If yes, date <br />If yes, explain <br />Page 19 <br />