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Print Form <br /> (OfF <br /> DEPARTMENT OF PUBLIC SAFETY CARD NUMBER <br /> �! ALCOHOL AND GAMBLING ENFORCEMENT DIVISION <br /> 445 Minnesota Street Suite 222 (Office Use Only) <br /> St.Paul,MN 55101 <br /> Phone(651)201-7507 TDD(651)282-6555 <br /> Fax(651)297-5259 <br /> APPLICATION FOR RETAILER'S(BUYER'S)CARD FOR LIQUOR AND WINE <br /> PLEASE RETURN THIS APPLICATION WITH FEE$20.00 <br /> ISSUING AUTHORITY TYPE CODE BUYER'S CARD EXPIRES IDENTIFICATION # <br /> City of Mounds View <br /> PRINT NAME OF LICENSEE(AS SHOWN ON LICENSE BUSINESS NAME(DBA) <br /> UI )j0I'\\o '�'�t Ye, LAC <br /> BUSINESS ADDRESS COUNTY BUSINESS PHONE <br /> � 3 )Ao i rr.,m c R5 Z qp-�I Y7 <br /> CITY,STATE,ZIP CODE AUTHORIZED SIGNATURE <br /> PS 9135(12/09) <br />