05-22-2017 Council Packet - Laserfiche WebLink

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Form SP -0 LICENSE APPLICANT: Pursuant to Minnesota statute 270.72 Tax Clewwxce: Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Miamsota business tax identification number and the social security number of each license applicant. Under the Minnesota Govenunent Dam Practices Act and the Federal Privacy Act of 1974, we are required to advise You Of the fbIlowing regarxiing the use of this itatrtnation: I - 11is infbrmation may be umd to deny the issuance, renewal or transfer of your licw3e in the event you owe the Minnesota Department of Revenue delinquent tans, penalties or interes4 2. Upon receiving this information, die licensing authority wil I supply it only to the Minnesota Departmem of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to die Internal Revenue Service; 3. Failure to supply this infomation 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: Renew at e Hauler LICENSING AUTHORITY: of Qroa2JHcwm9a ComV, Minn Agota LICENSE RENEWAL DATE: May 31, 2017 PERSONAL INFORMATION (trapplicable): Applicant's Name Bruce Wuollet Applicant's Address 14000 Veit Place Rogers, MN 55374 city state zip Social Security Number: BUSINESS INFORMATION (If applicable): BusinessName Ve..ft. Contiiner Corp DBA Veit Disposal Svstems Business Address 14000 Veit Place Rogers, MN 5gU4 city State zip MINNESOTA TAX IDENTIFICATION NO:. 288542B FEDERAL TAX IDENTIFICATION NO: 41-1663417 If a Minnesota Tax Identification number is not required, pleasc explain on the reverse side. Bruce Wuoilet / Di Signature Position (Officer, Partner, atc.) Date