01-13-2020 Council Work Session Packet

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State of Minnesota License Applicant Information Under Minnesota law (M.S. 270.72), the agency issuing you this license is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you that: • This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue delinquent taxes, penalities, or interest; • The licensing agency will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service; • Failing to supply this information may jeopardize or delay the issuance of your license or processing your renewal application. Please fill in the following information and return this form along with your application to the agency issuing the license. DO NOT RETURN THIS FORM TO THE DEPARTMENT OF REVENUE. Please print or type Name of license being applied for and license number (if renewal): License Number #: Licensing Authority (name of city, county, or state agency issuing license): License Renewal Date: PERSONAL INFORMATION: , - - Applicant's last name Applicant's first name and middle initial Social Security Number , Applicant's address City State Zip Code BUSINESS INFORMATION: Business name , Business address City State Zip Code Minnesota tax identification number Federal tax identification number If a Minnesota tax identification is not required, please explain on the reverse side of this form. Applicant Signature: Signature Title Date