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10/04 <br />Directions <br />APPLICATION FOR RENEWAL OF ANNUAL INTOXICATING LIQUOR, <br />WINE, 3.2 PERCENT MALT LIQUOR, AND SETUP LICENSES <br />City of Orono <br />2750 Kelley Parkway <br />P.O. Box 66 <br />Crystal Bay, MN 55323 <br />Phone: (952)249-4600 <br />This form must be filled out with typewriter or by printing In ink. If the application is by an <br />Individual person, by such person; If by a corporation, by an officer thereof ; if by a partnership, <br />by one of the partners; if by an association or corporation, by tho manager or managing <br />officer. <br />License type: (check all that apply) <br />I] On Sale Intoxicating Liquor ($5,000.00) <br />□ Wine ($2000.00) <br />Sunday Liquor ($200.00) <br />S Club ($200.00) <br />Setup ($100.00) <br />3.2% On Sale ($100.00) <br />3.2% Off Sale ($50.00)HI Off Sale Intoxicating ($150.00) <br />License year _______2005_______(January 1 - December 31) <br />1. Name of appilcant/licensee (name of individual, partnership, association or corporation): <br />Business Trade Name <br />Business Address "11^ AuwW S u Qn)r\0 <br />(City) <br />Mailing Address (if different) <br />(SSr“ (Ctly) <br />Licensee's Minnesota Tax Identification Number <br />Phone <br />(2p) <br />(W <br />Licensee's Federal Tax Identification Number ^1* <br />2. If the above named licensee is an individual, complete the following: <br />a. <br />Individual Name (First)(Middle)(Last)Date of Birth <br />HoSiAddfSi (StSii) (cityj j2-j------------------ <br />If the above named licensee is a partnership, association, or corporation, complete the followina for <br />each partner/officen ^ <br />______________a. <br />Partnw/Pffl <br />Home Address <br />M. <br />MOnM '(SoM«)JkcT <br />(Middle) , <br />Uftf tAtlJ <br />Partr <br />HotneAddfM fop? <br />(Jity) <br />(MM <br />(Last) <br />PartnertOfflgpfName . (First) <br />\ Pf <br />(zw <br />(Last) <br />.is t i i. uI i ilifITTj., <br />(Middle). . <br />iSSi.i <br />(Last)isii I Oats or Birth