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iCITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> Date of Application 11 -30 -1 <br /> BUSINESS NAME /)tti) Cekrreitt ` /' Phone 789-718-0 <br /> BUSINESS ADDRESS / Y w y /0 A./&- <br /> (street) <br /> ./&(street) <br /> MOi VIE'J /((A/ s'Sfta <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> J6FFf.eL1 CUop►J G6o <br /> �L 3LO&rV Gre <br /> HAVE YOU EVER HAD A LICENSE REVOKED? /00 If yes, attach <br /> 411 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 ,,FLQ c' i i Df}-L <br /> (please print) Last First Full Middle <br /> Date of birth r/ / S / C-13 ,1 <br /> mo day year <br /> 111 Applicant's signature <br />