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CITY Cr <br /> OUNDD S CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW,MN 55112 <br /> f G LICENSE APPLICATION FORM <br /> Date of Application 101 ( 1t <br /> s• <br /> Business Name h ct C r. `, <br /> :Ihir r r e Phone <br /> Business Address .2-573 1/2. WPC 11447 j Lt5 / filo um'5'I//PCU Riti Ss//Z <br /> Owtlners/Corporate Officers/Associates/Partners (name and title:) <br /> f l oPhck (A)(cci -E• 0 ut7nev o-6 cryoga L1 1,i <br /> Have you ever had a license revoked? 1 0 If yes,attach explanation. <br /> References: Cities where previously or currently license for same activity(name of City and <br /> year(s) licensed) <br /> C.214)44-. ,4 Lt) S-Lore +;n <br /> /4vi6._ 14�4-1 f o 19c cc 119(4 ,:, kt.c4 c A i/ t ci Cap L'r cd <br /> .6Li5r4cS. <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 /> • <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 /> Applicants's Full Name /I/Cti 0\ (.1J rct`YCO- <br /> (Please print) <br /> Date of Birth 111111111111111111t/ <br /> Applicant's Signature A, U, <br />