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The Commonwealrh of,VlassachUSetxs <br /> ^�— <br /> The Alcoholic Beverages Control Commission <br /> _ 239 Causeway Street,Suite 200 <br /> Boston,:VLA 02114 <br /> Telephone: 617-7273040 <br /> �._.. FAX: 617-727-1268 <br /> FORM A <br /> LICENSEE PERSONAL INFORMATION SHEET <br /> THIS FORM MUST BE COMPLETED FOR EACH: <br /> A. NEW LICENSE APPLICANT <br /> B. APPOINTMENT OR CHANGE OF MANAGER <br /> IN A CORPORATION CJ <br /> C. TRANSFER OF LICENSE (RETAIL ONLY-SEC. 12 & SEC. 15) <br /> (Please check which transaction is the subject of an application accompanying this Form A.) <br /> PLEASE TYPE OR PRINT Al I INFORMATION <br /> �LL QUESTIONS MUST BE ANSWERED AND TELEPHONE NUMBERS PROVIDED OR <br /> APPLICATION WILL NOT BE ACCEPTED. <br /> 1. LICENSEE NAME Y'/jG/'Q d/Qm <br /> (NAME AW IT WILL APPEAR ON THE LICENSE) <br /> 2. NAME OF (PROPOSED) MANAGER Z oLi mens QJS/4 4�?rj C/ <br /> 3. SOCIAL SECURITY NUMBER <br /> 4. HOME (STREET) ADDRESS �3 /tic i/1 Sf/eef CO�u/f NI H <br /> 5. AREA CODE AND TELEPHONE NUMBER (S): (Give both,your home teiephone and a number at which <br /> you can be reached during the day). <br /> DAY TIME - 160F))�yao- '7711-YHOME,# 6ToB �) yo - 97` 'l <br /> 6. PLACE OF BIRTH: /RkTS fQ M T DATE OF BIRTH: _�/may <br /> 8. REGISTERED VOTER: C YES NO 8A. WHERE ?: Jdarn 5hA <br /> 9. ARE YOU A U. S. CITIZEN: _ C YES NO ! L �} <br /> .U. CCUnTAND DA7E OF iV uTi <br /> Ur 70N (iF .'P P: (J.,S- J/I �. �f 90 3*17 <br /> (Submit proof of citizenship and/or naturalization such as Voter's Certificate, Birth Certificate or <br /> • Naturalization Papers) <br /> (Over) <br /> n <br /> CJ <br /> 1 - -:x <br />