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COMPANY INFORMATION <br /> Corporation Name Corporation Address City <br /> F1 '�110.� ��`z535 -to��,�15 �ew <br /> 5 <br /> State Zip •Email •Phone t <br /> rOxCu5�CkVke Apt�`c YVv1C( 'COIM Ex.(123)456-7890 <br /> Valid Email Required <br /> APPLICANT INFORMATION <br /> •Applicant Name Applicant Address City State Zip <br /> gow, 1ct 3 v► b r, ku A) 51 12 <br /> Email <br /> f 05c,"Co')t � y l CC)VVI <br /> Valid Email Required <br /> Fax ` 1(0` •Phone 1 (q 5 2>y63 --�114 Phone z <br /> Ex.(123)456-7890 Ex.(123)456-7890 Ex.(123)4S6-7890 11 <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 its <br /> determination on said application.I acknowledge that providing,or failing to provide,such information may affect the City's determination <br /> on said application.I understand this information will be made available to the City of Mounds View,its City Council,agents and <br /> representatives,as well as the Minnesota Department of Revenue,the Internal Revenue Service,or any other person or entity authorized by <br /> law to receive said information.I release the City of Mounds View from any and all liability for its receipt and use of data received pursuant <br /> to this application. <br /> Applicant Signature Date <br /> M M/DD/YYYY <br /> Format:MM/DD/YYYY <br /> Once your application is submitted and accep-Le-d by the City, <br /> you will automatically be sent an email to make payment.Thank You. <br /> 2/2 <br />