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• <br /> THIS FORM MUST BE COMPLETED AND SUBMITTED EACH YEAR <br /> City of St. Anthony <br /> 3301 Silver Lake Road <br /> St. Anthony, MN 55418 <br /> Directions: Please complete and return with the Retail 3.2 Beer Application. <br /> Date: 6115 1 91-4 <br /> 61WcH St) RIN �) C- <br /> 1. True Name: (Last, Fust, Middle) <br /> 3 5 3 I AYE PLS . MN 554C4, W 7).- 1 8 i (wl) <br /> 2. Residence Address: (Number, Street, City, State) 3. Phone Number: <br /> SHE R—E' PUNJAS. <br /> 3goo - S ILVE& LRKE RpAD .Sr AN7YOH <br /> 4. Business Address: (Number, Street, City, State) 5. Phone Number: <br /> J <br /> 6. Place of Birth: (County, City, State) 7. Date of Birth (Mo/Day/Yr) <br /> 8. U.S. Citizen Yes Naturalized Yes t,-- If yes, give-date and place. OCT �q <br /> No Nc <br /> 9. If you have ever used or been known by a name or names other than the true name given in <br /> #1 above, list such name (s) and information concerning dates and places where used. <br /> Names Dates Places, and Circumstances <br /> 10. Marital Status: Single Widowed_ Married_V"Separated_ Divorced_ <br /> Od : i6- 94A . * 300 . 00a <br />