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Print Farm <br />ql�DEPARTMENT OF PUBLIC SAFETY CARD NUMBER <br />ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br />445 Minnesota Steel Suite 222 (Office We Oullg <br />St, Paul, MN 55101 <br />" Phone (651)201-9509 TDD (651) 282-6555 <br />Fay (651)29Y5259 <br />APPLICATION FOR RETAILER'S (BUYER'S) CARD FOR LIQUOR AND NINE <br />PLEASE RETURN THIS APPI.TCATIC)N WITH FFF S20.06 <br />ISSUING AUTHORITY <br />TYPE CODE <br />BUYER'S CARD EXPIRES <br />IDENTIFICATION <br />City of Mounds View <br />PRINT NAME OF LICENSEE (AS SHOWN ON LICENSE <br />DO <br />BUSINESS NAME GH A) /� ( <br />1?05'44rFM.+i3 lky1Goy /.cfd'g4 Ny,G <br />✓rNaS 4bc- <br />BUSINESS ADDRESS <br />COUNTY <br />BUSINESS PHONE <br />eS35'* t1,5. //f )/d <br />elsm S. 17'voi <br />F(%'�AC 6lw,ii <br />CITY, STATE, ZIP CODE <br />AUTH941ZED SIGNATURE <br />U. tad) .TV rl N <br />// v <br />PS 9135 (12N9) <br />