05-22-2017 Council Packet - Laserfiche WebLink

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Form SP -CI LICENSE APPLICANT: Pursuant to Minnesota statute 270,72 Tax Clearance: Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of cach license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we am required to advise you of the following regarding the use ofthis information: I . This infarmation may be used to deny the issuance� renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnewta Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service; 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following information and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. LICENSE BEING APPLIED FOR OR RENEWED: Garbage Hauler LICENSING AUTHORITY: QLq of Orono, Hpnn Min County. Mimesota LICENSE RENEWAL DATE: ___Wy 31, 2017 PERSONAL INFORMATION (if applicable): Applicant's -1 a 4 Applicant's Address_ 9 __ _ V St. S g7 city state zip Social Security Number: " T' -:1 AZ4, ee r" BUSINESS INFORMATION (if applicable): Business Name Business Address �Z3 5 1 tA � I AL., a D 6, o S"Is city State Zip MINNESOTA TAX IDENTEFICATION NO- 11f?-1V9r3 FEDERAL TAX IDENTEFICATIONNO: -/// - 1Y Y If T4 If a -Minnesota, Tax Identification number is not required, please explain on the reverse side. Signature Position (Officer, Partner, etc.)