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Form SP -CI <br />LICENSE APPLICANT: <br />Pumuent to Minnesota statute 270.72 Tax Clearance: Issuance of Ucenees, the licensing aulhorhy to <br />required to provide to the Minnesota Cmrnnt48loner of Revenue your Minnesota bushen tax <br />Iddon number and the social security number of each license applicant. <br />Under the Minrawla Government Date Prac lass Act and lire Federal Privacy Act of 1974. we are <br />required to advise you of itre following regarding the use of this 1n1 mnaWn:- <br />1. This Information may be used to deny the Dance, renewal or banter of your ficerae In <br />the event you owe the Minnesota Depwiment of Revenue delinquent twm, peroltim or <br />intim <br />2. Upon receiving this information, the licensing authority will supply It only to the Mlnnesfa <br />Deparhmft of the Deparkrrent Revenue ue may supplyis i F� too the Inben al PAmmue Service; t <br />3. Follure to supply this information may Jeopardb w or delay tlar processing of your licensing <br />is ahce or raneml application. <br />Please supply the following Information and return along with your application to the agency is uing <br />the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br />LICENSE BEING APPLIED FOR OR RENEWED: Q0 Sat ,gam Suoft LWuor <br />LICENSING AUTHORITY: City of Orom. Hbnnapjn Couft M1130MM— <br />LICENSE RENEWAL DATE: January 1 17 <br />PERSONAL INFORMATION (If applicable): <br />ApplirarWe Name Jlffin „art Krinoen <br />FdSQ (Middle) (Lest) •_ <br />Applicanirs Address_ 1365 Maolew000d Drive_ Lona Lake MN 55356 <br />(sem) (city) (W) imp) <br />Soca[ Security Number: <br />BUSINESS INFORMATION (If applicable): <br />Business Name. Spring Hill fie Club <br />Business Address: 72§ County Road 6 WAMto MN 0301 <br />(sv"q (ab) (Ma) (ap) <br />MINNESOTA TAX IDENTIFICATION NO; 31 <br />FEDERAL. TAX IDENTIFICATION NO: 41-01695951 <br />If a Minnsata Tax Identification number a not required, please explain on the reverse slde. <br />POPS <br />