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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,.First.Floor <br /> i ON Boston,MA.02114 <br /> CORI REC UEST FORM <br /> DEB4RAHB.GOLDBERG JEANIVI.LDRIZIo,ESQ. <br /> TREASURER AND RECEIVER 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 ("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: PSWM--19-0020 LICENSEE NAME:Darby's Natural Markets LLC CITY/TOWN: Mashpee <br /> IIF EXaING LICENSEE <br /> APPLICANT INFORMATION <br /> LAST NAME: Eames FIRST NAME: Rory MIDDLE NAME. nn <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): Tagliziferri PLACE OF BIRTH: Plymouth,MA <br /> DATE OF BIRTH, S:SN; I ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: r DRIVER'S LICENSE#: STATE LIC,ISSUED: Massachusetts El <br /> GENDER: FEMALE HEIGHT; 5 �r 9 .� WEIGHT: 165 EYE COLOR: brawn <br /> La <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Harwich STATE: MA ZIP: <br /> FORMER ADDRESS: <br /> CITY/TOWN: - STATE: MA ZIP: <br /> PRINTANaD SIGN <br /> PRINTED NAME: Rory Eames APPLICANT/EMPLOYEE SIGNATURE: E* <br /> . ... ........... <br /> NOTARYINFORMATION <br /> on this before me,the undersigned notary public,personally appeared <br /> name of document signer),proved to me through satisfactory evidence of identification,which were M L-1- <br /> to <br /> be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> M�4 <br /> NOTARY <br /> Pm=nwilfl di M� hcretts <br /> oomduw F. r%pgrch 13,21 <br /> 4I; 1 <br /> C <br /> DIVISION USE ONLY <br /> REQUESTED BY: <br /> SIGNATUREOF COR!-AU71 ORIZE0 EMPLOYFE <br /> The D01 Identify Theft Index PIN Number is to be completed by those applicants that have been issued an identity Theft <br /> PIN Number by the DCJI.Certified agencies are required to provide all applicants the opportunity to include this <br /> Information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are <br /> required to be submitted to the DCJI via mail or by fax to 1617)660.4614. <br />