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ALCOHOLIC BEVERAGES CONTROL COMMISSION <br /> BENEFICIAL INTEREST CONTACT- Individual, (Formerly known a a Personal <br /> erson la direct orn Form) <br /> redirect beneficial interest,with <br /> Please complete a Beneficial Interest-Individual sheet for all individuals) <br /> or without ownership,in this license. This includes people with a financial interest and people without financial interest(i.e. <br /> board of directors for not-for-profit clubs). All individuals with direct or indirect financial interest must also submit a CORI <br /> Authorization Form. <br /> An individual with direct beneficial interest is defined as someone who has interest directly in the proposed licensee. For <br /> example,if ABC Inc is the proposed licensee,all individuals with interest in ABC Inc are considered to have direct beneficial <br /> interest in ABC Inc(the proposed licensee). <br /> An individual with indirect beneficial interest is defined as someone who has ownership in a parent level company of the <br /> proposed licensee. For example,if ABC Inc is the proposed licensee and is 100%owned by XYZ Inc,all individuals with interest <br /> in XYZ Inc are considered to have an indirect beneficial interest in ABC Inc(the proposed licensee). <br /> Middle Name Last Name Shahid Suffix <br /> Salutation Mr. First Name Ei= �� <br /> Authorized Representative <br /> Social Security Number Date of Birth <br /> Title: <br /> Primary Phone: __ Email <br /> 71 <br /> Mobile Phone: Fax Number <br /> Alternative Phone: <br /> Business Address <br /> Street Number: 44 Street Name: Falmouth Road <br /> State: MA — <br /> City/Town: Mashpee -------' <br /> Country: USA <br /> Zip Code: 02649 <br /> Mailing Address ❑ Check here if your Mailing Address is the some as your Business Address <br /> Street Number: Street Name: <br /> = — — <br /> City/Town: Centerville <br /> State: MA <br /> Zip Code: 02632 <br /> Country: =USA — <br /> itT pes of Interest(select alhat apply) <br /> X Director ❑ Landlord ❑ LLC Manager <br /> ❑ Contractual ❑ <br /> ❑ Management Agreement ❑X Officer <br /> ❑ LLC Member Other <br /> ❑ Partner ❑ Revenue Sharing ❑ Sole Proprietor ❑X Stockholder ❑ <br /> Citizenship/Residency Information <br /> Are you a Massachusetts Resident? (F)Yes o No <br /> Are you a U.S.Citizen? (F)Yes ()No <br /> Criminal History <br /> Have you ever been convicted of a state,federal,or military crime? OYes (Q No If yes i please provides. affidavit <br /> explaining the charges. <br />