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vo.`4..c�uo vi:4m rnA o1Glgzati4iS L'ANOId <br />C�joos <br />�OC717 ��e �� . <br />������� ��������� <br />Pursuant fo Mirre��sota �iatu�� 2✓f3.72 °�ax Cle�r�rac�o 1ssa�a�tc� �f �i��ns��P ihe lic�nsing <br />�uthorit� � r�q�ired to prc�vide ia 4he Min��sa�fia Commi�sior�er of R�v�r��� Yo�r �innes�ta <br />t�usin�ss t� od��t���ivn n�tmbe�' �d 4E�� so�i�l s�cu�iy nu�b�r of e��h licens� apptican�. <br />l��ot�r t�e Minr�esota Goverr�rraeni Pra�tices A�i an� the �ederal Privacy Act of 1974, we are <br />required to advise yesu of the f�lfa��ng regarding ih� us� af thi� anforrriation: <br />�) Thi� info�r►a4i�ri m�y be used tca deny the i�su�nce; renewal �r �ransf�r.of your <br />lic�r�se in the e�ent you owa the flAi�n�sota i3epartmen� of R�ve�ue detinquent <br />t�xes, p�n�Bt'ses or intea°est; �he lic�nsing authority �viH supPfy �i or�ly to ih� <br />�) Upon r�ceiv€ng thts #nforrr,ae4o�, <br />i�iin��s�t�� Depar�m�e t�he fl pa�tme t f Re�rerru��r�r Y, �PP�Y �'► s inf�rma�ion to <br />fnforrnat&or� Ag ee <br />� the lntem�l R�v�rrue Service; <br />3� Failure io ��ppl� thi� ar�fo�rnaiior� may jeop�rdize or deiay th� proc�ssing of your <br />4icensie�g inst�r��c� or re�re�eal appll�at6on. <br />, � � - . . : � �: .: . � ���.� . , . ,� - <br />: . -,�- <br />■ � • :� _ : � � . �, • : � , �. : <br />� �� � . � � � �r. � <br />_: �. ; �r =.R '"�_. !. :"" � <br />. , �� <br />� � � � � <br />► ..., i <br />1;, ._ <br />' • � ` �. '' :�-. ' . � . � � � x: .�. � ^ . <br />� . *' <br />' ` %. '� ; ,... <br />f � �'. 1 <br />` <br />1 <br />i �.� � , <br />�°il� .St21t� ' �� <br />SOCiAL S�CURIiY �: <br />� � �. i� � . . _ <br />�. . <br />� - <br />BIJSINESS NAME: <br />; �s�- <br />City �ta�e �4p <br />u <br />�,: �. * � <br />- -; �- <br />� ' , �t, _ _ _. <br />s_ <br />. <br />, ,- .- �. -. • . . - _ . <br />' SiI�iVA7l1��: ��i�� <br />