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Form SP -CI <br />LICENSE APPLICANT: <br />Pursuant to Minnesota statute 270.72 Tax Clearance: Issuance of Licensee, the licensing authority is <br />required to provide W the Minnesota Commissioner of Revenue your Minnesota business tax <br />identifleation number and the social security number of each Iloense appiioont. <br />Under the Minnesota Government Data Prackes Act and the Federal PrNacy Act of 1974, we are <br />required to advise you of the following regarding the use of this Information: <br />1. This information may be used to deny the issuance, renewal or transfer of your license in <br />the event you awe the Minnesota -Department of Revenue delinquent taxes, penalties or <br />Interest; <br />2. Upon receiving this information, the licensing authority will supply k only to the Minnesota <br />rtment of Revenue. However, under the Federal Exchange of Information Agement <br />the Department of Revenue may supply this Information to the Internal Revenue Service; <br />9. Failure to supply this information may jeopardize or delay the processing of your llowsing <br />Issuance or renwal application. <br />Please supply the following information and return tong with your application to the agency issuing <br />the license. DO NOT RETURN To THE DEPARTMENT OF REVENUE. <br />LICENSE BEING APPLIED FOR OR RENEWED: <br />On <br />d S <br />-Sale <br />LICENSING AUTHORITY: ,., Gity of Orono. <br />HennVin <br />Coul ti[ Mlonesota <br />LICENSE RENEWAL DATE: 1 <br />2 1 <br />PERSONAL INFORMATION (If applicable): <br />Applicant's [dame . Christo her <br />GemWi <br />(Fist) <br />{Mrddlel <br />"Q <br />Applicant's Address 9 5525 5r Ave North. _ - <br />l rah <br />{street) <br />(city) (State) (Zip) <br />Social Secufity Number: <br />�. <br />BUSINESS INFORMATION (if applicable): <br />Business Name: WqMte CounMIClub <br />Business Address: Zoo VAgll glvd West,.,.... <br />Wavzeta <br />. MSV---- - 5394 <br />(Sheat) <br />(city) (State) MP) <br />MINNESOTA TAX IDENTIFICATION NO: §U7666 <br />FEDERAL. TAX IDENTIFICATION NO: 41-0778776 <br />If a Minnesota Xax ldentificapon number Is not required, please exptatn on the reverse side. <br />General Manager ted - -., <br />Pop 5 <br />