Application For Representatives Or Salespersons Identification Card
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Application For Representatives Or Salespersons Identification Card Form. This is a Minnesota form and can be use in Alcohol And Gambling Enforcement Division Statewide.
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Tags: Application For Representatives Or Salespersons Identification Card, PS 99073-04, Minnesota Statewide, Alcohol And Gambling Enforcement Division
CARD NUMBER
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
ALCOHOL AND GAMBLING ENFORCEMENT DIVISION
444 Cedar Street Suite 222
St. Paul, MN 55101-5133
Phone (651) 201-7507 TDD (651) 282-6555
Fax (651) 297-5259
APPLICATION FOR REPRESENTATIVE’S OR SALESPERSON’S IDENTIFICATION CARD NAME
FEE PER PERSON CARD IS $20.00 PLEASE RETURN THIS APPLICATION WITH FEE
LICENSE TYPE
EXPIRATION DATE
ID NUMBER
NAME
NAME OF FIRM
NAME
STREET ADDRESS
(Office Use Only)
BUSINESS PHONE
CITY, STATE, ZIP CODE
AUTHORIZED SIGNATURE
PS 99073-04 (12/09)
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