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JUL -11 -95 TUE 12:52 IDS FINANCIAL SERVICES FAX N0, 6712621 P,03 <br />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 j. 7 TL E GRiv9 AA Re f r rn, 4 (fo•ciA fsc., <br />Trade Name <br />Mailing Address e/S E ,L$rrsF_ C4/wAA4 <br />,2n txrrz, CA,v44 <br />individual Partnership Corporation !/Non- Profit _Other <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Bach Partner or Owner Percentage of Ownership <br />Operating Location(s) - List all Locations: <br />1. SP00tvg, Pq 1, _ tt?rii: 2. <br />C,4.v44,9 <br />Classification <br />Primary Nature of Business: <br />Check all applicable. <br />1. Restaurant 2. Club 3. Bar <br />4. Bowling alley 5. ---On/Off Sales <br />6. _Off Sale Only 7. Special Event <br />Total Gross Receipts of Entire Establishment <br />Gross Receipts from Liquor Sales Included Above 4/67°0 <br />Seating Capacity Total Bar Only <br />License in Effect? Yes No Pg9) 0J.ry G <br />Licensing Authority Lrr4J CA.,A4/9 <br />Address S,S' aca '� PAS Mti <br />License Number <br />Effective Date -�9$ Expiration Date f/I4JQC <br />License Ever RevO ed/ uspended? Yes C/No If yes, ate <br />If yes, explain <br />Page 12 <br />ST /1 <br />