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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 ='-/Z---; //, <br /> BUSINESS NAME '-///:/- 2 /14-4417.---)4 6-/R-41 6 Ur'Phone <br /> BUSINESS ADDRESS 231 //.% 4' 4 z) C /c-� A4,/ 5 47 <br /> (street) <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> HAVE YOU EVER HAD A LICENSE REVOKED? "\i6 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 /> A.)L 9z <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 Al_L %/4 P 6_4„1/ - A /4/e/ <br /> (please print) Last First Full Middle <br /> Date of birth 7 / % / Z�— <br /> mo day year / <br /> Applicant's signature (�C/ 7;_-' %i: - y <br />