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all OF <br /> v <br /> ©MSA CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> OEN MOUNDS VIEW,MN 55112 <br /> °8h4_ParmacitAs <br /> LICENSE APPLICATION FORM <br /> Date of Application q- G%- c1 C1 <br /> Business Name WI ' Phone <br /> Business Address Al /11 . <br /> Owners/Corporate Officers/ sociates/Partners (name and title:) <br /> Ak 17 <br /> Have you ever had a license revoked? If yes, attach explanation. <br /> References: Cities where previously or currently license for same activity(name of City and <br /> year(s) licensed) <br /> Aft/A - <br /> Applications for the following licenses must complete the applicable section on the reverse side <br /> of this form: <br /> ► Bowling Alleys Gasoline Stations <br /> ► Automobile Sales / Kennels <br /> ► Cigarette and Tobacco ► Restaurants <br /> ► Dance Halls <br /> I hereby certify that information provided on this application is true and hereby correct and <br /> understand any misrepresentation made herein may be ground for denial of this application. <br /> 0-t •re?5. <br /> Applicants's Full Name e cc 1 d ,' Y'1..,e ; I e , r <br /> (Please print) <br /> Date of Birth 1 0/ /'7 / 1/ <br /> ) / <br /> /] <br /> Applicant's Signature 47....e.A._,,,x_ed.i.„1„ , -� (_16,.-1-ti. <br />