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Form SP -CI <br />LICENSE APPLICANT: <br />Pursuant to Minnesota statute 270.72 Tax Clearance: Issuance of Licenses, the lic--Dsing authority is required to <br />provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the <br />social security number of each license applicant. <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required tD advise <br />you of the following regarding the use of this information. <br />I . This infbrmation may be used to deny the issuance, renewal or transfer of your license in the event you <br />owe the Minnesota Department of Revenue delinquent taxes, penalties or interest, <br />2. Upon receiving this information, the licensing authority will supply it only to the Minnesota <br />Department of Revenue. However, under the Federal Exchange of Infbrmation Agreement the <br />Department of Revenue may supply this information to the Internal Revenue So -vice; <br />I Failure to supply this information mayjeopardim or delay the processing of your licensing issuance of <br />renewal application. <br />Please supply the following inforrnation and return along with your application to the agency <br />issuing the license. DO NOT RETURN TO THE DEPARTMENT OF RiEVENUE. <br />LICENSE BEING APPLIED FOR OR RENEWED: Garbaize Hauler. <br />LICENSING AUTHORITY: CLty of Orono, Herinenin CgppZ sota <br />LICEIZE RENEWAL DATE: ___May 31,2017 <br />PERSONAL INFORMATION (if applicable): <br />Applicant's Name <br />Applicant's Address. <br />Social Security Number: 044 U <br />BUSINESS INFORMATION (irappitcabie): <br />Business Natne <br />Business <br />MINNESOTA TAX IDENTIFICATION' NO: J195jeavI <br />$ 1 4!5T -3 <br />S zip <br />state zip <br />FEDERAL TAX IDENTIFICATION NO: 41-layo95 <br />If a Minnesota Tax Identification number is not required, please explain on the reverse side. <br />Signature I Position (Officer, Partner, etc.) <br />