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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> VIMIM Boston,MA 02114 <br /> REQUEDEBORAHB.GOLDBERG CO� L�T FO JEAN M.LORIZIO„E'SQ. <br /> TREASURER AND REC`E'IVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("ABCC'') has been certified by the Criminal History Systems Board to access <br /> conviction and pending Criminal Offender Record Information ("CORP'). For the purpose of approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criminal record check will be conducted on me,pursuant <br /> to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE INFORMATION <br /> ABCC NUMBER: LICENSEE NAME: ASIS Group,Inc. CITY/TOWN: Mashpee,MA <br /> Of EXISHNG LICENSEE) •� <br /> APPLICANTINFORMATION <br /> LAST NAME: FsZhid FIRST NAME: Zohaib MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS{IF APPLICABLE): I PEACE OF BIRTH: Faisalabad,Pakistan <br /> DATE OF BIRTH: SSN: I ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#:i STATE EIC.ISSUED: Massachusetts <br /> GENDER: HEIGHT: - l WEIGHT: EYE COLOR: <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP: <br /> PRINTAND SIGN r <br /> :r - <br /> PRINTED NAME: Zohaib Shahid APPLICANT/EMPLOYEE SIGNATURE: <br /> ---••1111 �� / <br /> NOTARYINFORMATION <br /> On this before me,the undersigned notary public,personally appeared Zohaib Shahid <br /> r � <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were Ilzj <br /> to be the person whose name is signed on the preceding or attached document,andnowledge to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> NOTARY <br /> j RS F. <br /> �0M�1'2aErpf�P��'% <br /> DIVISION USE ONLY — o <br /> a <br /> REWESTEO BY: '.• f�'H� ��Aeo <br /> 4 <br /> sl Rfyl D o %i gSSAMCNP <br /> HEus{�'ft: N <br /> The Otll Wen"fy Theft Indea PIN Number IF to be mmpleted by those applImnu that Faye been issuedan IdentRyTheft //� 0 <br /> T�41'tY....... <br /> �•''• <br /> PW Number by the DCH.CerFfged agendas are requked to provide all applicants tha opportunity N IncludeB <br /> Information to—sure Rho accuracy of the COM request prox s, ALL CORI soquast Poems that Inddu4a this flald ora !Il I I It 54�ti <br /> nquirad to ba rubmittad to tho DCA via..9 or by faa to(517166"624. <br />