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Form SP -CI <br />LICENSE APPLICANT: <br />Pursuant to Minnesota statute 270.72 Tax Clearance: Issuance of Licenses, the licensing 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 we required to advise <br />you of the following regarding the use of this inbrmation: <br />I - This infbimudion 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, dw licensing authority will supply it only to the Minnesota <br />Department of Revenue. However, under the Federal Exchange of Inflarmation Agreement the <br />Department of Revenue may supply this information to the Internal Revenue Service; <br />3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or <br />renewal application. <br />Please supply the following information and return along with your application to the agency <br />issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE, <br />LICENSE BEING APPLIED FOR Hauler, <br />LICENSING AUTHORITY: Qfty of Orono. Honepin CogM. Minnesota <br />LICENSE RENEWAL DATE: May 31, 2017 <br />PERSONAL INFORMATION (if applicable): <br />Applicant's Namea)M-, ��,eA �P,� <br />Applicant's Address —T-3 <br />zip <br />Social Security Numben. <br />BUSINESS INFORr4ATION (if applicable)., <br />Business Name <br />Business Address —7300 010%'ZJ--7G of.A, ALZ <br />uty - state zip <br />qLja <br />oqel,�B <br />MINNESOTA TAX IDENTIFICATION NO: <br />FEDERAL TAX IDENTIFICATION NO: %2 <br />If a Minnesota Tox Identification number is not required, please explain on the reverse side. <br />-Z 1h t -44- <br />Partner, etc.) Date <br />