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Da Lc of application Pe( <br />rid <br />BUSINESS NAMr_ c ": 44U----. /a ` t S Ti/(' -- <br />U11;i1NES;; ADDRESS. •y 6 <br />(SCcctj r <br />(state) (zip code) <br />c <br />P I101J r <br />OWNERS/CORPORATE 01'FICERS/ASSOCIATES/PARTNERS (name 6 title): <br />e: <br />HAVE. YOU EVER HAD A LICENSE REVOKED?/LC If yes, attach explanation. <br />TYPE OF LICENSE REQUESTED: It' A:M ��, c)V TU 11 P <br />REVERENCES: CITI1rS WHERE PREVIOUSLY OR CURRENTLY LICENSED FOR SAI4E <br />ACTIVITY (name of city and year(s) licensed) <br />i <br />LOCATION FOR WIIICII LICENSE IS RL'QUESTL'D (if applicable) <br />OWNEIt OF PREMISES (if applicable) % N <br />Aphlicants, for the following license must complete the applicable section <br />on the reverse side of this form: <br />amusement devices/bingo/bowling alleys/dance halls/ garbage <br />collection/gasoline stations/kennels/peddlers/solicitors/ <br />restaurants. <br />I hereby certify that information provided on this application is true <br />and correct and understand that any misrepresentation made herein may <br />be grounds for denial of this Application. <br />%/ <br />Applicant's name <br />ase Iprint <br />Applicant's signatures <br />� j Date of Council approval <br />Date of birth S 1/ <br />i <br />-7 1 ( L / <br />License number <br />New Renewal_ <br />(rev. 5/77) <br />