01/28/2019 BOARD OF SELECTMEN Agenda Packet

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ALCOHOLIC BEVERAGES CONTROL COMMISSION BENEFICIAL INTEREST CONTACT- Individual(Formerly known as a Personal Information Form) Please complete a Beneficial Interest-Individual sheet for all individual(s)who have a direct or indirect beneficial interest,with or without ownership, in this license. This includes people with a financial interest and people without financial interest(i.e. board of directors for not-for-profit clubs). All individuals with direct or indirect financial interest must also submit a CORI Authorization Form. An individual with direct beneficial interest is defined as someone who has interest directly in the proposed licensee. For example,if ABC Inc is the proposed licensee, all individuals with interest in ABC Inc are considered to have direct beneficial interest in ABC Inc(the proposed licensee). An individual with indirect beneficial interest is defined as someone who has ownership in a parent level company of the proposed licensee. For example,if ABC Inc is the proposed licensee and is 100%owned by XYZ Inc,all individuals with interest in X12 Inc are considered to have an indirect beneficial interest in ABC Inc(the proposed licensee). Salutation Mr. First Name Zohaib Middle Name Last Name Shahid Suffix Title: Authorized Representative Social Security Number Date of Birth Primary Phone: Email: Mobile Phone: Fax Number Alternative Phone: Business Address Street Number: 44 Street Name: Falmouth Road City/Town: Mashpee State: MA Zip Code: 02649 Country: USA Mailing Address ❑ Check here ifyourMading Address is the some as your Business Address Street Number: Street Name: City/Town: State: MA Zip Code: Country: USA Types of Interest(select all that apply) ❑ Contractual ❑X Director ❑ Landlord ❑ LLC Manager ❑ LLC Member ❑ Management Agreement Z Officer ❑ Partner ❑ Revenue Sharing ❑ Sole Proprietor ❑ Stockholder ❑ Other Citizenship Residency Information Are you a U.S.Citizen? (F)Yes ()No Are you a Massachusetts Resident? ©Yes Q No Criminal Histor Have you ever been convicted of a state,federal,or military crime? ()Yes Q No if yes, please provide an affidavit explaining the charges.