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, <br />�� <br />, <br />�� <br />�� f�Da� <br />� <br />� <br />p ��o� <br />POg� ��QS <br />• ' ' • :� ` '� 1'� .ti. <br />� ` '. � <br />• ! l. 1 <br />ft ° "��"`� LICENS� APPLTCA'I°IOl� FORM <br />l <br />Date of Applicatic�n � � � � � 9 � � <br />u ° s I�Tame �� � �%vY�-�'�-�'�-- Phone � �� -�' — / ? `� � <br />n . <br />Address <br />pwners/C�rporate O£ficerslAsso�iates/Partners (�e and titlee} <br />Have you ever had a license re�oked? �L� If yes, atia�h explar�ation. <br />References: Cities where previously or curren�iy li�ense for sarne activity {name of Cziy and <br />y��r(s) i����ea� ... . . ... . <br />Applicat�ons for the following licenses musi coffiplete the applicable section on the reverse side <br />o� this form: <br />Bowiing Ali�ys <br />Au�omobile Sales <br />Cigarette and Tobacco <br />Da�ace Halls <br />Ga.soline Stations <br />Ke�n�Is <br />Restaur�nts <br />', I hereby certify that information provided on tl�is applicaiian is #ue and hereby correct and <br />j utiderstand any misrepresentation made hezein ffiay be ground for denial of this appiic�tion. <br />�� ' �� z��mpl l5 ��'-��� �.��r�! �^� � ���- �� �'�-°�� �c� � <br />A I ts F' <br />pp ic� s <br />Daie af B�h <br />Appli�ant's Signati: <br />(Piease p�int) <br />� <br />������ <br />