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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,.first Floor <br /> Boston,MA 42114 <br /> CORI REQUEST FORM <br /> DEBOR"B.GOLDBERG JEAN M.LDRIZIO,ESQ. <br /> TREASURER AND RECEIVER GENERAL CIIAIR'IIAN" <br /> The .Alcoholic Beverages Control Con=sszoan. ("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: 00170-PK-0278 LICENSEE NAME:Darby's Natural Markets LLC CITY/TOWN: Dennis <br /> (IF EXISTING LICENSEE) <br /> APPLICANT INFORMATION <br /> LAST NAME: Eames FIRST NAME: Rory MIDDLE NAME: NN <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): agllaferrl PLACE OF BIRTH: <br /> DATE OF BIRTH: _ SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC,ISSUED: Massachusetts ` <br /> GENDER: FEMALE HEIGHT: 5 T 9 ,►. WEIGHT: 165 EYE COLOR: brown <br /> ..................... <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: NIA ZIP: <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: <br /> P'RINTAND SIGN <br /> PRINTED NAME: Rory Eames APPLICANT/EMPLOYEE SIGNATURE: <br /> IVO TARY INFORMATION <br /> On this before me,the undersigned notary public,personally appeared ")ey- <br /> (name <br /> of document signer),proved to me through satisfactory evidence of identification,which were <br /> to 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 /> NOTARY <br /> LYMPIA li MOS <br /> N*fy PuNlo,Cftftftealth of hWr achumsaft <br /> card" n0Mao I3, <br /> Y <br /> DIVISION USE ONLY <br /> REQUESTED BY: <br /> SIGNATUREQF CORI-AUTHORIZED EMPLOYEE <br /> The DUI 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 CONI request process. ALL CORI request forms that include this field are <br /> required to be submitted to the DCII via mail or by fax to(617)6604614. <br />