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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> Boston,MA 02114 <br /> CORI REQUEST FORM JEANM.LORIZ10,ESQ. <br /> DEBORAHB.GOLDBERG CHAIRMAN <br /> TREASURER AND RECEIVER GENERAL <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 ("CORI"). 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. <br /> CITY/TOWN: Mashpee,MA <br /> (IF EXISTING LICENSEE) <br /> . E== <br /> APPLICANT INFORMATION —� <br /> FIRST NAME: rZo�h�lb �� MIDDLE NAME: <br /> LAST NAME: <br /> I <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH:�— L— <br /> DATE OF BIRTH: I � SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> LL DRIVER'S LICEL--I ENSE#t: STATE LIC.ISSUED: MaSSaChU5Ett5 _ <br /> MOTHER'S MAIDEN NAME: <br /> MALE HEIGHT: WEIGHT: 165 EYE COLOR: <br /> GENDER: Brown <br /> CURRENTADDRESS: LL����•��JJ ����• <br /> CITY/TOWN: Centerville STATE: MA ZIP: 02632 <br /> FORMER ADDRESS: <br /> CITY/TOWN: <br /> STATE:�� ZIP: --- <br /> LL��--------�1 <br /> ,A <br /> PRINT AND SIGN <br /> PRINTED NAME: Zohaib Shahid <br /> APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARYINFORMATION <br /> On this L}day of February,2019 before me,the undersigned notary public,personally appeared Zohaib Shahid <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were driver's license <br /> to be the person whose name is signed on the preceding or attached document,and ac� rledged to m�that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> p�`..no7 <br /> moo? o� <br /> �i y;9S�MNEP�\x, <br /> DIVISIONUSEONLY moi, '!� SACHUSE.. <br /> LREQUESTEDDY: <br /> fy Theft IndI.ex PIN Number is to bas ae completed by those applicants that have been Issued ftyan IdentityTheft <br /> 'de at <br /> vide all <br /> s the opportunity <br /> ensure the a.curby the DCJI. faeC. <br /> d egthei CORI rre es are e lu prose equired to pro ALL CORI relqusit forms thet includ othis field aInclude ,.o quessubmitted to the DCII vie mail or by fix to(617)660-4614. <br />