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CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> Date of Application II -3Q <br /> BUSINESS NAME Arm v ! v CE -441L JI//t/cf, Phone 78,./-710 <br /> BUSINESS ADDRESS 2417S- gwy to /VC. <br /> v� <br /> (street) <br /> 1,iOuM1ja1 41(fill✓ <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> )r •F2ey t�i-ov&) GCo <br /> BL000r Cra <br /> HAVE YOU EVER HAD A LICENSE REVOKED? /10 If yes, attach <br /> explanation. , <br /> REFERENCES: CITIES WHERE PREVIOUSLY OR CURRENTLY LICENSED FOR <br /> SAME ACTIVITY (name of city and year(s) licensed) <br /> Applicants for the following license(s) must complete the <br /> applicable section on the reverse side of this form: <br /> amusement devices, bowling alleys, dance halls, garbage <br /> collection, gasoline stations, kennels, and restaurants. <br /> * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> I hereby certify that information provided on this application is <br /> true and correct and understand that any misrepresentation made <br /> herein may be grounds for denial of this application. <br /> Applicant's name ALO"711 Dfl-L <br /> (please print) Last First Full Middle <br /> Date of birth -C—/ / 5T / Sy <br /> mo day year <br /> Applicant's signature <br /> 6d2 / 1c&_ <br />