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1. <br />2. <br />4. <br />APPLICATION FOR LICENSE TO <br />SELL TOBACCO PRODUCTS AND <br />TOBACCO RELATED DEVICES <br />(OnikuiK* No. 164, Second Series - Adopted 12/08^) <br />MM Make check payable to: City of Orono <br />Mailing address: P.O. Box 66 <br />Crystal Bay> MN 55323 <br />FEE: $100.00 (February 1-January 31)I Im lo:i- <br />DATE <br />Applicant's Full Name <br />> cVvcL-g, \OCX (\ <br />FIRST MIDDLE LAST <br />Applicant's Home Address <br />HOUSE NUMBER <br />C>0 C <br />STREET HOME PHONE <br />CITY STATE <br />3. Applicant's Business <br />•'■A or <br />TYPE OF BUSINESS <br />\ Wc* A-S <br />BUSINESS PHONE <br />^ HXO 9tTAb ViL^ovr> Rc> <br />BUSINESS NAME STREET ADDRESS <br />'^D US <br />MAILING ADDRESS CITY <br />Describe how the actual physical exchange of the tobacco, tobacco product, or <br />tobacco related device between the customer and the licensee or employee takes <br />place. P CLoXi»YysQj*~ rv\ rKvislcL^c <br />I HEREBY MAKE APPLICATION FOR LICENSE TO SELL TOBACCO. TOBACCO <br />PRODUCTS. OR TOBACCO RELATED DEVICES AT THE ABOVE LOCATION SUBJECT <br />TO THE LAWS OF THE STATE OF MINNESOTA AND THE ORDINANCES OF THE CITY <br />OF ORONO. <br />Signaturt L/Data <br />Itm issuance of a Scansa undarthis onSlnanca ba conakiarad a pdvHaga and not an abaotuta dgbt oftha appncvtt <br />andahabnotanUtlathaholdarloanautomatkmnawalafthaboanaa. <br />I211f7.j <br />i