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1. <br />2. <br />3. <br />4. <br />APPLICATION FOR LICENSE TO <br />SELL TOBACCO PRODUCTS AND <br />TOBACCO RELATED DEVICES <br />(OnUmnct No. 164, Stcood Series • Adopted 12/0W7) <br />^ iff/ VJ' <br />Make check payable to: City of Orono <br />Mailing address: P.O. Box 66 <br />Crystal Bay, MN 55323 <br />FEE: $100.00 (February 1-January 31)/ <br />DATE <br />Applicant's Full Name <br />'yontJ ___/7 <br />FIRST MIDDLE LAST <br />Applicant's Home Address <br />HOUSE NUMBER <br />/1APiC_£^^ <br />STREET <br />ICi- <br />HOME PHONE <br />fi\AJ 3 f / <br />CITY STATE <br />Applicant's Business <br />V C a ) *C fJCC STCf\C <br />TYPE OF BUSINESS BUSINESS PHONE <br />33^0 S'/'P^CL»tO€ 2>rl <br />BUSINESS NAME STREET ADDRESS <br />^^o.Sox: AJfitWe /^Iaj rs'39^ <br />MAILING ADDRESS CITY <br />Describe how the actual physical exchange of the tobacco, tobacco product, or <br />tobacco related device betweenthe customer and the licensee or emplm^e takes <br />place. <CtcA7!t>yT\jt^ s. _ y/in <br />I HEREBY MAKE APPLICATION FOR LICENSE TO SELL TOBACCO. TOBACCO <br />PRODUCTS. OR TOBACCO RELATED DEVICES AT THE ABOVE LOCATION SUBJECT <br />TO THE LAWS OF THE STATE OF MINNESOTA .^ND THE ORDINANCES OF THE CITY <br />OF ORONO. <br />Signature <br />iInI^2- <br />Oat« <br />n»lsautnc9 0falic9ns» undtr this onUnanmMbtconaidtnd a piMtgttnd net an ab$okifo right of th* applicant <br />and shall not anUtla lha heldarto an autemaUcfanawaioflha tcanaa. <br />laiirs <br />. '1^ ^