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Commonwealth of Massachusetts <br /> — _ Alcoholic Beverages Control Commission <br /> 95 Fourth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JEA.V.N.LOR17.I0,EsQ. CORI REQUEST FORM <br /> 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: 00073-RS-0670 LICENSEE NAME:Mashpee Oriental,Inc. CITY/TOWN: Mashpee <br /> IIF EMISTING LICENSEEI <br /> APPLICANT INFORMATION <br /> LAST NAME: Wang FIRST NAME: ouxiang MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Fuzhou China <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> I MOTHER'S MAIDEN MAIDEN NAME: Dairong Hu DRIVER'S LICENSE#: i STATE LIC.ISSUED: M8S58CI1uSBttS <br /> GENDER: MALE HEIGHT: S . 7 . WEIGHT: 137 EYE COLOR: Brown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Newton STATE: MA ZIP: 02461 <br /> FORMER ADDRESS: <br /> 1 <br /> CITY/TOWN: Minhou,Fujian China STATE:[� ZIP: 350200 -- _ <br /> PRINT AND SIGN <br /> PRINTED NAME: YOU Xiang Wang APPLICANT/EMPLOYEE SIGNATURE: E_ " <br /> NOTARY INFORMATION <br /> On this �t�p � f 201 before me,the undersigned notary public,personally appeared You Xiang Wang <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were driveIrS license --� <br /> to be the person whose name is signed on the preceding or attached document,and a nowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> NOTARY <br /> JENNIFER M.DA CRUZ <br /> .DIVISION USE ONLY <br /> �Pj<< Notary Public <br /> R Massachusetts <br /> EQUESIEni,y <br /> 0 <br /> SIGNAIURt Or CORI-AUIHORILt EMPLOYEE yJ6 cs` My Commission Expires <br /> The OCII+ounnly Tnull IIiUta PIN Nunmer Is to ue cmnpleled by loose applicants Ihal have been Issued an Idein then dfYW'y'J Dec 14,2D23 <br /> PIN Nurnue by Inc OCII Certified ase—,s are required to provide all applicants the appoll—ty to mtlude this <br /> mlonnatlon to ensure the accuracy of lire CORI request pl Ite All CORI request loans that Include this field are <br /> required to be submitted to the OCR via..it or by faa to 16171 660 4614. ' <br />