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97-968Council File # � Ordinance � Green Sheet # J ���� Presented By Referred To ���i�f�,i� � RESOLUTION CITY OF SAINT PAUI,, MiNNESOTA � Committee: Date 1 2 3 RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is hereby approved 4 5 6 Yea Nava Absent 7 B a e� � 8 Bostrom �` 9 Harris i 0 Me ar __�� 14 Morton � � 15 "�' 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Secretary 19 20 21 By: � � ��._.,� 22 � I 23 Approved by Mayora Date �{I��� 24 25 26 By: �, 1! 27 Requested by Department of: • - • - -- - - • - - _i . n-e. • - ., By: l/'{'V�"^i" �" /� Form Approved by City Attorney �_.- l By: � f � a�-,..�� Approved by Mayoz for Submission to Council By: �� �q� DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE ����� LIEP/Licensin CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE �OEPARTMENTOIRECTOR OCITYC�UNd� Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK NUM9ERFON MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR. For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION RE�UESTED. Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347). RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment? _ CIB COMMITTEE _ YES NO _�� 2. Has this person/firm ever been a ciry amplayae? — YES NO _ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee? SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO Ezplain atl yas answers on separate sheat antl attaeh to green sheet INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i � ����'.�� APFc 2�s ���� C1�� ����� EY ADVANTAGESIFAPPROVED: DISAOVANTFGES IF APPROVED. DISADVANTAGES IF NOTAPPROVED: .� ��i C�t�� JUL 2 3 ;; �� TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINAyCIAL INFORF4ATION: (EXPLAIN) Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 ` In Tracker .23 aPP�n aece�ved J App'n Processed License ID # 23347 License Type: Auto Repair Garage CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302 Contact Name j. Date to Councii Pubiic Hearing I Not+ce Sent to � 3 MN 55123 Home Phone: 454-8715 Labels Ordered: District Council #: n � ��/`( � �� � Notice Sent to Public: // {I / ` / /'� Ward #: � Departmentf Date Inspections Comments C1ty Attorney �' �'' t �• I'� ` Environmental Heaith �J • Fire �' �' `� ��� • License Site Plan Received: . � � Lease Received: �- � � -�l �,�„F,� .��. �� �� Police � 2l -��- �. � . Zoning � ,�' '��"' Q . \ �; � CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC PLEASE TYPE OR PRINI' IN INK Company Nazne: Corporalion / PaAnaship / Sole fropr If b ess 's in� gi��e date of incorporalioi �o�� s As`� � IIusiness Address: GC sa� naa� Betueen H�hat cross strcets is the business located? � Are tttie premises now o s cup'ed7 �K./ � at Mai] To Address: seren nadrc�, Applicant Infomadon: � Name and Tille: Qi Fust � !.Siddle Home Address: ��'� 11 � S S �3 i f � L�"U S S Lesi ��� � CITY OF SAINT PAUL �ce ar L;cense, Inspeccions and Em�vonmertai Protection s5luraascS.dm3oa � Sc�nPeul,hfumesota 55103 � (FIi1166-W9p Gx(61])2669I7y��� y Title ' Sircet Addrem V V Cif� �Siete � Zip /� / Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t� Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X .� Date of azrest: Where� Charge: Comiction: Sentence: List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be refetred to as to the applicanYs character: NAME �. ADDRES� �) i PHONE hold, tormer3y held, or may ha��e an interest in: �) /� Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation: 2f18797 Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ � _ � � F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "� Strat \cmc Aeeyou going to ha��e a manager orassistant in this business7 please complete the following infonnation: NGddle Initinl HomeAddresT: Sircet;:ame Cin' YES (`kidrn) Citq S�ate � Zip Phone Numbcr NO If the manager is not the same as the operator, Last S�ete Zip Detc of Bvth Phane Number Please list your employment hisfory for the pre�rious five (5) }'zaz period: If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey): Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth Home Addma: Svat Name FinlName A�iddle I�utial Hame Addrees: Street t�.ame City tete Zip Phone Numher Last DateoFB'uth S�ate Zip Phane Number MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72) (fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta�t identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following regazding the use of the Minnesota Tax Identification Number: - This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s withholding or motor vehic3e excise ta�tes; - Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal Revenue Service. Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent, 10 I2iver Park Plaza (612-296-618] ). Social Security Number: '�1 (� ��SS � M'vmesota Tax Idrntification Number: ' ` '�� _ If a Minnesota Tax Idrntification I�um6er is not requ'ued for the business being oper' ated, �3cate so tiy pla��ng �"X" &t the'5 2.'18-57 List all other officers of the corporation: ' U OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH Council File # � Ordinance � Green Sheet # J ���� Presented By Referred To ���i�f�,i� � RESOLUTION CITY OF SAINT PAUI,, MiNNESOTA � Committee: Date 1 2 3 RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is hereby approved 4 5 6 Yea Nava Absent 7 B a e� � 8 Bostrom �` 9 Harris i 0 Me ar __�� 14 Morton � � 15 "�' 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Secretary 19 20 21 By: � � ��._.,� 22 � I 23 Approved by Mayora Date �{I��� 24 25 26 By: �, 1! 27 Requested by Department of: • - • - -- - - • - - _i . n-e. • - ., By: l/'{'V�"^i" �" /� Form Approved by City Attorney �_.- l By: � f � a�-,..�� Approved by Mayoz for Submission to Council By: �� �q� DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE ����� LIEP/Licensin CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE �OEPARTMENTOIRECTOR OCITYC�UNd� Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK NUM9ERFON MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR. For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION RE�UESTED. Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347). RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment? _ CIB COMMITTEE _ YES NO _�� 2. Has this person/firm ever been a ciry amplayae? — YES NO _ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee? SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO Ezplain atl yas answers on separate sheat antl attaeh to green sheet INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i � ����'.�� APFc 2�s ���� C1�� ����� EY ADVANTAGESIFAPPROVED: DISAOVANTFGES IF APPROVED. DISADVANTAGES IF NOTAPPROVED: .� ��i C�t�� JUL 2 3 ;; �� TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINAyCIAL INFORF4ATION: (EXPLAIN) Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 ` In Tracker .23 aPP�n aece�ved J App'n Processed License ID # 23347 License Type: Auto Repair Garage CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302 Contact Name j. Date to Councii Pubiic Hearing I Not+ce Sent to � 3 MN 55123 Home Phone: 454-8715 Labels Ordered: District Council #: n � ��/`( � �� � Notice Sent to Public: // {I / ` / /'� Ward #: � Departmentf Date Inspections Comments C1ty Attorney �' �'' t �• I'� ` Environmental Heaith �J • Fire �' �' `� ��� • License Site Plan Received: . � � Lease Received: �- � � -�l �,�„F,� .��. �� �� Police � 2l -��- �. � . Zoning � ,�' '��"' Q . \ �; � CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC PLEASE TYPE OR PRINI' IN INK Company Nazne: Corporalion / PaAnaship / Sole fropr If b ess 's in� gi��e date of incorporalioi �o�� s As`� � IIusiness Address: GC sa� naa� Betueen H�hat cross strcets is the business located? � Are tttie premises now o s cup'ed7 �K./ � at Mai] To Address: seren nadrc�, Applicant Infomadon: � Name and Tille: Qi Fust � !.Siddle Home Address: ��'� 11 � S S �3 i f � L�"U S S Lesi ��� � CITY OF SAINT PAUL �ce ar L;cense, Inspeccions and Em�vonmertai Protection s5luraascS.dm3oa � Sc�nPeul,hfumesota 55103 � (FIi1166-W9p Gx(61])2669I7y��� y Title ' Sircet Addrem V V Cif� �Siete � Zip /� / Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t� Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X .� Date of azrest: Where� Charge: Comiction: Sentence: List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be refetred to as to the applicanYs character: NAME �. ADDRES� �) i PHONE hold, tormer3y held, or may ha��e an interest in: �) /� Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation: 2f18797 Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ � _ � � F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "� Strat \cmc Aeeyou going to ha��e a manager orassistant in this business7 please complete the following infonnation: NGddle Initinl HomeAddresT: Sircet;:ame Cin' YES (`kidrn) Citq Please list your employment hisfory for the pre�rious five (5) }'zaz period: S�ate � Zip Phone Numbcr NO If the manager is not the same as the operator, Last S�ete Zip Detc of Bvth Phane Number If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey): Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth Home Addma: Svat Name FinlName Hame Addrees: Street t�.ame City tete Zip Phone Numher Last DateoFB'uth S�ate Zip Phane Number MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72) (fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta�t identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following regazding the use of the Minnesota Tax Identification Number: - This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s withholding or motor vehic3e excise ta�tes; - Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal Revenue Service. Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent, 10 I2iver Park Plaza (612-296-618] ). Social Security Number: '�7 (� ��SS � M'vmesota Tax _ If a Minnesota Tax Idrntification I�um6er is not requ'ued for the business b A�iddle I�utial Idrntification Number: ' ` '� eing oper' ated, �3cate so tiy pla��ng �"X" &t the'5 2.'18-57 List all other officers of the corporation: ' U OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH Council File # � Ordinance � Green Sheet # J ���� Presented By Referred To ���i�f�,i� � RESOLUTION CITY OF SAINT PAUI,, MiNNESOTA � Committee: Date 1 2 3 RESOLVED: That applicarion (ID #23347) for an Auto Repa'u Garage License by Wayne F. Anderson DBA Hillcrest Certicare (Wayne Anderson, Owner) at 1581 W}ute Beaz Avenue North be and the same is hereby approved 4 5 6 Yea Nava Absent 7 B a e� � 8 Bostrom �` 9 Harris i 0 Me ar __�� 14 Morton � � 15 "�' 16 Adopted by Council: Date � 17 18 Adoption Certified by Council Secretary 19 20 21 By: � � ��._.,� 22 � I 23 Approved by Mayora Date �{I��� 24 25 26 By: �, 1! 27 Requested by Department of: • - • - -- - - • - - _i . n-e. • - ., By: l/'{'V�"^i" �" /� Form Approved by City Attorney �_.- l By: � f � a�-,..�� Approved by Mayoz for Submission to Council By: �� �q� DEMq7MENTNFFlGER:OUNCIL DATE INITIATED GREEN SHEE ����� LIEP/Licensin CONTACT PERSON & PHONE INITIAVDATE INITIAVDATE �OEPARTMENTOIRECTOR OCITYC�UNd� Christine Rozek 266-9108 A��G ❑arrm OCYTYCLERK NUM9ERFON MUST BE ON COUNCILAGENDA BV (DA7E) p011TING � BUDGET DIREGTOR � FIN. & MGT. SERVICES DIR. For hearin : ( �� ORDER �MAYOR(ORASSI5TANT) ❑ TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE) ACTION RE�UESTED. Wayne Anderson DBA Hillcrest Certicare requests Council approval of its application for an Auto Repair Garage located at 1581 White Bear Avenue North (ID 23347). RECOMMENDA7iON5. Apprwe (A) er liejaet (q) pER50NAL SERVICE CONTRACTS MUST ANSWER THE FOLLOWING QUESTIONS: _ PIANNING COMMISSIQN _ qV1�SERVICE COb1MISS10N �� Has tnis personttirm ever worked under a contract !or this tlepartment? _ CIB COMMITTEE _ YES NO _�� 2. Has this person/firm ever been a ciry amplayae? — YES NO _ ois7qiCTCOURi _ 3. Does this personRirm possess a skill not normally possessed By any curceot ciry employee? SUPPORTS WHICN GOUNCII.OBJECTfVE? YES NO Ezplain atl yas answers on separate sheat antl attaeh to green sheet INITIATING PROBLEM, ISSUE. OPP�RNNIN (Who, What, When. Where. Why): p � i � ����'.�� APFc 2�s ���� C1�� ����� EY ADVANTAGESIFAPPROVED: DISAOVANTFGES IF APPROVED. DISADVANTAGES IF NOTAPPROVED: .� ��i C�t�� JUL 2 3 ;; �� TOTAL AMOUNT OF TRANSAC710N S COST/REVENUE BUDGETED (CIRCLE ONE) YES NO FUNDIfdG SOURCE ACTIVITY NUMBER FINAyCIAL INFORF4ATION: (EXPLAIN) Greensneet# 37946 L.I.E.P. REVIEW CHECKUST Date: 4115/97 ��1 ` In Tracker .23 aPP�n aece�ved J App'n Processed License ID # 23347 License Type: Auto Repair Garage CompBny Name: Wayne F. Anderson DBA: Hillcrest Certicare Business Addresss: 1551 White Bear Avenue North Bus)ness Phone: 771-D302 Contact Name j. Date to Councii Pubiic Hearing I Not+ce Sent to � 3 MN 55123 Home Phone: 454-8715 Labels Ordered: District Council #: n � ��/`( � �� � Notice Sent to Public: // {I / ` / /'� Ward #: � Departmentf Date Inspections Comments C1ty Attorney �' �'' t �• I'� ` Environmental Heaith �J • Fire �' �' `� ��� • License Site Plan Received: . � � Lease Received: �- � � -�l �,�„F,� .��. �� �� Police � 2l -��- �. � . Zoning � ,�' '��"' Q . \ �; � CLASS III LICENSE APPLICATION THIS APPLICATION IS SUBJECT TO REVIEW SY I'F� PU13LiC PLEASE TYPE OR PRINI' IN INK Company Nazne: Corporalion / PaAnaship / Sole fropr If b ess 's in� gi��e date of incorporalioi �o�� s As`� � IIusiness Address: GC sa� naa� Betueen H�hat cross strcets is the business located? � Are tttie premises now o s cup'ed7 �K./ � at Mai] To Address: seren nadrc�, Applicant Infomadon: � Name and Tille: Qi Fust � !.Siddle Home Address: ��'� 11 � S S �3 i f � L�"U S S Lesi ��� � CITY OF SAINT PAUL �ce ar L;cense, Inspeccions and Em�vonmertai Protection s5luraascS.dm3oa � Sc�nPeul,hfumesota 55103 � (FIi1166-W9p Gx(61])2669I7y��� y Title ' Sircet Addrem V V Cif� �Siete � Zip /� / Date of B' `' ' Plaee of Birth: ���cJ �� Home Phone; " S� `, ' I t� Ha��e you ever been comicted of any felony, crime a violation of any city ordinance other than traffic? YES I�TO X .� Date of azrest: Where� Charge: Comiction: Sentence: List the names and residences of thrce persons of good mora] character, living w�ithin the Twin Cilies Metro Area, not related to the applicant or financially interested in the premises or business, who may be refetred to as to the applicanYs character: NAME �. ADDRES� �) i PHONE hold, tormer3y held, or may ha��e an interest in: �) /� Ha�•e any of lhe abo��e named licenses ever been revoked? YES �_ NO ff yes, list the dates and reasons for revocation: 2f18797 Are yuu going to operate this business personally? �YES NO If not, who wi11 operate it? Q/) „Q� \ � _ � � F'vatName MiddleLtitial (�faidrn) i.a+t Deteo£Birth "� Strat \cmc Aeeyou going to ha��e a manager orassistant in this business7 please complete the following infonnation: NGddle Initinl HomeAddresT: Sircet;:ame Cin' YES (`kidrn) Citq Please list your employment hisfory for the pre�rious five (5) }'zaz period: S�ate � Zip Phone Numbcr NO If the manager is not the same as the operator, Last S�ete Zip Detc of Bvth Phane Number If business is a partnership, please include the folloa�ing information for each partner (use additional pages if necessaey): Fint Name Middle Ltitial (:Naidrn) LaR Da4 of Birth Home Addma: Svat Name FinlName Hame Addrees: Street t�.ame City tete Zip Phone Numher Last DateoFB'uth S�ate Zip Phane Number MII�INESOTA TAX IDENTTFICATION NUMBER - Pursuant to the Laws of Mnu�esota, 1984, Chapter 502, Article 8, SecUon 2(270.72) (fax Clearance; Issuance of Licenses), licensing authorities ara required to provide to the State of Minnesota Commissioner of Revenue, the Minnesota business ta�t identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Aci of 1974, we are required to adi�ise you of the following regazding the use of the Minnesota Tax Identification Number: - This infmmation may be used to deny the issuance or renewal oFyour license in ihe eveni you owe Mim�esota sales, employer s withholding or motor vehic3e excise ta�tes; - Upon receiving tlris information, the licensing authority uill supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of 3nformation Agreement, the Departrnent of Revenue may supp]y tivs iuformation to the Intemal Revenue Service. Minnesota Ta�c Identification Ntunbers (Sales & Use Tae Number) may be obtained from the State of Minnesota, Business Recorcis Departrnent, 10 I2iver Park Plaza (612-296-618] ). Social Security Number: '�7 (� ��SS � M'vmesota Tax _ If a Minnesota Tax Idrntification I�um6er is not requ'ued for the business b A�iddle I�utial Idrntification Number: ' ` '� eing oper' ated, �3cate so tiy pla��ng �"X" &t the'5 2.'18-57 List all other officers of the corporation: ' U OFFICER TITLE HOME HOME BUSINESS DATE OF NAME (OfficeHeld) ADDRESS PHONE PHONE BIRTH