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• <br /> j14A) � 5 - /yr/X <br /> CITY OF MOUNDS VIEW <br /> 2401 HIGHWAY 10 <br /> MOUNDS VIEW, MN 55112 <br /> LICENSE APPLICATION FORM <br /> Date of Application /0 /;/ <br /> BUSINESS NAME rf:M Plip11-11`c'-"" 6904P‘;/ii d-0 - Phone <br /> BUSINESS ADDRESS /7--4/ lam. <br /> (street) <br /> aAY T77/1>'9 IVv V35 <br /> (city) (state) (zip code) <br /> OWNERS/CORPORATE OFFICERS/ASSOCIATES/PARTNERS (name and title: ) <br /> J a4 Art X}P—c-s <br /> A 4/9.2 5 hz- A'/�� <br /> HAVE YOU EVER HAD A LICENSE REVOKED? /V C) 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 /> fps /9.f3 - J7 <br /> Applicants for the following license(s) must complete the <br /> applicable section on the reverse side of this form: <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 ilk-D)AL Aii3 _3k`ivhh S <br /> (please print) Last First Full Middle <br /> Date of birth 7 / 7 / L5`" <br /> mo day year <br /> Applicant's signature ( C <br />