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Pursuant to Minnesota Statutes 270C.72, the agency issuing you this license is required to provide, upon request, to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and 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: and 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; and Failure to supply this information may jeopardize or delay the issuance of your licensing or processing your renewal application. Please fill in the following information and return this form along with your application and other required documents to the Clay County Auditor Office. Do not return this form to the Department of Revenue. Licensing Authority: Clay County License Information Name of license being applied for: Personal Information Applicant's Name: Applicant's Address: Social Security Number: Business Information Business Name: Business Address: Minnesota Tax Identification Number: Place an X in the box if you do not conduct business as a business entity and therefore do not have a Minnesota business identification number. Signature: Date: (Street or PO Box number) (City) (State) (Zip Code) (Zip Code) (Street or PO Box number) (City) (State) License Applicant Information Auctioneer (Last name) (First name) (MI)