STATE OF MINNESOTA LICENSE APPLICANT INFORMATION
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Under Minnesota law (M.S. 270.72), the agency issuing you this
license is required to provide to the Minnesota Commissioner of
Revenue your Minnesota business tax identification number of the
Social Security number of each license applicant.

Under the Minnesota Government Data Practices Act and the Federal
Privacy Act of 1974, we must advise you that:

- This information may be used to deny the issuance, renewal or
  transfer of your license if you owe the Minnesota Department of
  Revenue delinquent taxes, penalties or interest;
- The licensing agency will supply it only to the Minnesota
  Department of Revenue. However, under the Federal Exchange of
  Information Act, the Department of Revenue is allowed to supply
  this information to the Internal Revenue Service;
- Failing to supply this information may jeopardize or delay the
  issuance of your license or processing your renewal application.

Please fill in the following information and return this form
along with your application to the agency issuing the license. Do
not return this form to the Department of Revenue.

-PLEASE PRINT OR TYPE-

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Name of license being applied for and license number

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Licensing Authority (name of city, county, or state agency issuing)

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License renewal date

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PERSONAL INFORMATION (if applicable):

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Applicant's last name     First name and initial  Social Security #

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Applicant's address            City            State       Zip

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BUSINESS INFORMAITON (if applicable):

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Business name

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Business address              City              State       Zip

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Minnesota tax identification #       Federal tax identification #

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If a Minnesota tax identification number is not required, please
explain on the reverse side of this form.

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Signature                     Title                      Date

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