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DocuSign Envelope ID: 00550633-1436-425D-A603-68CEE44A37A2 <br />I'I'int Farm <br />CARD NUMBER <br />DEPARTMENT OF PUBLIC SAFETY <br />ALCOHOL AND GAM SLING ENFORCEMENT AI FISION <br />445 Minnesnla Street Suite 222 Ofire use 04) <br />St, Paul, MN 55101 <br />01D PhQno (651) 201•7S67 TDD (651) 292.6555 <br />Fax (651) 297-5259 <br />APPLICATION FOR RETAILER'S (BUYER-S) CARD FOR LIQUOR AND WINE <br />PLEASE RETURN THIS APPLICATION WITH FEE $20.00 <br />ISSUING AUTHORITY <br />TYPE CODE I <br />BUYER'S CARD EXPIRES <br />IDENTIFICATION N <br />City of Mounds View <br />RWT NAUE OF LICENSEE (AS SHOWN ON LICENSE <br />BUSINESS NAME (DBA) <br />American Multi -Cinema, Inc <br />AMC Mounds View 15 <br />BUSINESS ADDRESS <br />COUNTY <br />BUSINESS PHONE <br />2430 Co Hwy 10 <br />Ramsey <br />ITY, STATE, ZIP CODE <br />A7 <br />Mounds View, MN, 55112 <br />ZRISR"IONATURE <br />V" (Ob "r <br />PS 9135 (12/09) <br />This form is for any business <br />purchasing alcohol from a <br />distributer to sell on -site. <br />It must be sent to State of MN. <br />