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8/412o21 <br />Revize online Forms <br />This application is NOT for: Intoxicating Liquor, 3.2 Percent Malt Liquor, Brew Pubs, Peddler/Solicitor/Transient Merchant, <br />Tattoo/Piercing/Painting, Therapeutic Massage, Christmas Tree Sales, Garbage/Recycling. <br />Background Check form and color copy of current drivers license or ID required for: Cigarette/Tobacco, Lawful Gambling, Pawn Shop, and <br />Adult Establishment. <br />Have you ever had a business License revoked? If yes, please attach explantion. <br />❑ Yes <br />0 No <br />COMPANY INFORMATION <br />Corporation Name <br />American Multi -Cinema, Inc <br />Corporation Address <br />11500 Ash Street <br />Explanation of license revocation if applicable <br />Choose File No file chosen <br />City State Zip Code <br />Leawood KS 66211 <br />* Email <br />licensespermits@amctheatres.com <br />Valid Email Required <br />Fax * Phone 1 Phone 2 <br />Ex. (123) 456-7890 913-213-2000 Ex_ (123) 456-7890 <br />APPLICANT INFORMATION <br />* Applicant First Name <br />Michelle <br />Applicant Address <br />11500 Ash Street <br />City <br />Leawood <br />* Email <br />licensespermits@amctheatres.com <br />Valid Email Required <br />Fax <br />Ex. (123) 456-7890 <br />MI <br />* Phone 1 <br />9132132000 <br />* Applicant Last Name <br />Portilla <br />State Zip Code <br />KS 66211 <br />Phone 2 <br />Ex. (123) 456-7890 <br />PRIVACY NOTICE: I understand the information provided in this application may be considered private or confidential data. I further <br />understand that I may not be required by law to provide such information. The purpose of providing such information is to aid the City in <br />https:llmoundsviewmn, rja.revize.comlreportsl155938 2/3 <br />