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Date of application 3 <br />RIISINESS NAME Pt10NE <br />%22 - <br />BUSINESS ADDRESS <br />stree <br />C <br />��lfyLL) -- (�LQJ <br />ZIP code) <br />OWNERS/CORPORATE OFFICERS/A[iSOCIATES/PARTNERS (name & title): <br />HAVE YOU EVER HAD A LICENSE REVOKED? <br />TYPE OF LICENSE REQUESTED: <br />_V i If yes, attach explanation. <br />v <br />REFERENCES: CITIES WHERE PREVTOUSLY OR CURRENTLY LICENSED FOR SAME <br />ACTIVITY (name of city and ycar(s) licensed) <br />(! Oe Ai P A A I , I — <br />LOCATION FOR WHICH LICENSE IS REQUESTED (if aopl.irable) <br />C ��✓.T��11 <br />OWNER OF PREMISES (if applicable) <br />Applicants for the follow.inq license mustcompleLe the applicable section <br />on the reverse side of this form: <br />�uvices/uingo/bowlinq.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 />Applicant's name )Of <br />(pleas print) I Date of birth C-_/ �. <br />Applicant's signatures <br />= = = = = = = =`/ = = = = = <br />0 Date of Council approval <br />License number <br />New __ Renewal <br />(rev, 5/77) � —' <br />