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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 95 Fourth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JEANM.LOnrzIO, sQ. CORI REQUEST FORM <br /> CHA %V" <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 /> AOCC LICENSE INFORMATION <br /> ABCC NUMBER: 00073-RS-0670 LICENSEE NAME: Mashpee Oriental,Inc. CITY/TOWN: Mashpee <br /> (IF odmN�ucl:Nsep <br /> APPLICANT INFORMATION <br /> LAST NAME: Shum FIRST NAME: Jenny MIDDLE NAME: Pui Ling <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Hyannis,MA <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): I <br /> MOTHER'S MAIDEN NAME: Mel Wah Shum DRIVER'S LICENSE#: I STATE LIC.ISSUED: New YOGIC 17-7111 <br /> r <br /> GENDER: FEMALE 7 HEIGHT: 5 WEIGHT: 141 EYE COLOR: Brown _--- <br /> CURRENT ADDRESS: JJJ <br /> f <br /> CITY/TOWN: ` STATE: NY ZIP: 11101 <br /> FORMER ADDRESS: <br /> CITY/TOWN: East Falmouth STATE: MA ZIP: 02536 <br /> PRINTAND SIGN <br /> PRINTED NAME: �211I1y$I1Unl APPLICANT/EMPLOYEE SIGNATURE: Bo il ll9c <br /> NOTARYINFORMAT►ON <br /> On this ,�„ � G� before me,the undersigned notary public,personally appeared TI211nM SwM <br /> (name of document signer),proved tome through satisfactory evidence of identification,which were <br /> to be the person whose name is signed on the precedinjaed document,and acknowledged tome that(he)(she)signed it voluntarily for <br /> its stated purpose. YANIRA PICHARDONotary Public-State of New NO.01P16364852 <br /> Qual,ii, inqueens Coun <br /> My OMMIssl <br /> DIVISION USEONLY <br /> REQUESTED RY: <br /> 5 A EOF 1A 7H0IZED 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 DC1I,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 /> requirecitobesubmittedtothe D01 v1amailorbyfaxto161716600.4614. <br />