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Form <br />SP:Ct <br />State of Minnesota <br />License Applicant Information <br />Undor Minnesota law (M.S. 270.72). the agency issuing you this Icons# is required to provide to the Minnesota Commissionor <br />of Revenue your Minnesota business tax identitication number and the Social Security number ol each license appicani <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of I97e. we must advise you thai; <br />• This intormation may be used to deny the issuance, renewal o. iranster of your license if yo; owe the Minnesota <br />Depaiiment of Revenue oelMiquerir taxas. penalties, or interest; <br />• The licensing agoncy will supply it only to the Minnesota Department of Revenue. However, under the Federal <br />Exchange of”Intormation Act. the Department of Revenue is allowed to supply tnis information to the Interna' <br />Revenue Serve#; <br />. Failing to supply this Information may jeopardize or delay the Issuance of your Icons# or processing your renewal <br />appication. <br />Please fill m the following information and return this form along wHh your application to the agency laauing tha license. <br />Do not return this form to the Oepertmant of Revenue. <br />Hwne ol i«erua being appiioO tar and hoenae number <br />Ucensing Au^toniy (name oi city. UQurey. or sttie agency tuwirg licerwei <br />Ucenae renewal date <br />Personal Information: <br />Fvsi neme one imaei <br />Appiieitfue»ddr»M <br />Sooel aeotfity numC^ <br />TSBBr <br />Business Information (If applicable): <br />Bwamosaneme <br />Buwness address &ISIB ^j^uoom <br />m HkM idsnencaion nuffiMf <br />If e Mfnneeote *#» fd^ntlSctthn number Is nef nquind, pfeeee •gpi»tn on Me netrerse eide e/ Ml# renii.