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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. <br />Legal Name of Applicant 41.77.1- 0.4 , i - . 4 4 9 R; C,ecn 71 o.ti ,9 SSoCATJ <br />Trade Name <br />Mailing Address C' r .I TTr2 r r4.vA.aA ,A .4Zi 744 CA.vA4,I M <br />ii7 <br />_Individual _Partnership _Corporation I/fton- 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. 4/Y0 .C77744 CAN4OA RA 2. <br />Classification <br />Primary Nature of Business: 12c,n e 7? y64 The Ac, -T Jv ; Se*f <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. scSpecial Event <br />Total Gross Receipts of Entire Establishment "o2 3 g 0 <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity /SO Total Bar Only <br />License in Effect? Yes No (A 't ;' C <br />Licensing Authority / T i i A r' C a .N A• A /,9 <br />Address SAS F 1 7 T i 1- r h AA) 4114 ,Q A <br />License Number <br />Effective Date / 14, , /a s Expiration Date //..24/4/-5 <br />License Ever Revoked /Suspended? Yes 1-"No If yes, date' <br />If yes, explain <br />Page 4 <br />