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1� Commonwealth of Massachusetts <br /> —_-\- Alcoholic Beverages Control Commission <br /> 95 Fourth Street, Suite 3 <br /> Chelsea,MA 02150 <br /> JEA.V,rI,LORlZLD,EsQ. CORI REQUEST FORM <br /> CIIAIRMA.V <br /> The Alcoholic Beverages Control Commission (t <br /> tABCCrr) 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,T 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: 00073-RS-0670 LICENSEE NAME:Mashpee Oriental,Inc. CITY/TOWN: Mashpee <br /> (IF EXI6TIN-LICENSEEI <br /> APPLICANT INFORMATION (� <br /> LAST NAME: Liu FIRST NAME: ih Chin MIDDLE NAME:I —� <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Kaohsiung Taiwan <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> L <br /> MOTHER'S MAIDEN NAME: Xiu Lian Li DRIVER'S LICENSE#: I STATE LIC.ISSUED: Massachusetts II <br /> GENDER: MALE I-I HEIGHT: 5 6 . WEIGHT: 193 EYE COLOR: grown <br /> CURRENT ADDRESS: <br /> I <br /> CITY/TOWN: Plymouth STATE: MA ZIP: 02360 1 <br /> FORMER ADDRESS: <br /> CITY/TOWN: Falmouth STATE: MA ZIP: 02540 <br /> PRINT AND SIGN <br /> PRINTED NAME: )Ih Chin Liu APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> On this r before me,the undersigned notary public,personally appeared A in Liu <br /> I(name of document signer),proved to me through satisfactory evidence of identification,which were driveY's license <br /> to be the person whose name is signed on the preceding or attached document,ands nowledged to me ( ,)(she)signed it voluntarily for <br /> its stated purpose. <br /> -- / NOTARY <br /> r r m t HIA A QONNOL-Y <br /> DIVISION USE ONLY ,� Notary Public <br /> �'� Cprttrtlpnwe2ti1�1QI �Uf <br /> REQUESTED BY _ (`fl{j1fT116Stxt C <br /> SIt:NAIllflf 0t CORI-4UIHORILfD EMPLOYEE Expires Feb,10, <br /> `l� <br /> The DCII menu(,Tr,eft We, I.be completed by Iliose auuricants uwt have been rs u,.an weouly theft <br /> ,IN Number oy the DUI Certified e9--all reVmred to P"Y'de all appb-itl the oppoilumty to-Jude thu <br /> li rnf.r ,,t,n to ensure the a .—y of the CORI request process ALL CORI oq—t forms that include this field are <br /> ,eyuired Io be,uhmitted Io the 001 via mail o,by fax to(617(660-4614. <br />