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art O <br /> CUPIDS CITY OF MOUNDS VIEW <br /> ;� 2401 HIGHWAY 10 <br /> MOUNDS VIEW,MN 55112 <br /> • e„,„,„•Partnego. <br /> LICENSE APPLICATION FORM <br /> Date of Application %� / 9 9d <br /> $ iness Name a26/4.14..d 771) a.,--rvkt-4-erg / <br /> Phone 723- ge. <br /> -Business Address , 9f/ /94 C ) <br /> Owners/Corporate Officers/Associates/Partners(name and title:) <br /> cif /cid-(--;-&41 <br /> Have you ever had a license revoked? 26 Ifes attach explanation. <br /> xplanation. <br /> References: Cities where previously or currently license for same activity(name of City and <br /> year(s)licensed) <br /> • <br /> Applications for the following licenses must complete the applicable section on the reverse side <br /> of this form: <br /> • <br /> ► Bowling Alleys ► Gasoline Stations <br /> ► Automobile Sales ► Kennels <br /> ► Cigarette and Tobacco ► Restaurants <br /> ► Dance Halls <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 41T-e/l/) 1//r,e /11141- ! /7/ Q 4d f <br /> / (Please print) <br /> Date of Birth 6i / A C*/ <br /> Applicant's Signature a ? ��'(JLF "772 <br />