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L4 Cointnonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 95 Fonrth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JEANA1.LORIZ10,ESQ. CORI UQUEST 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 propose 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 /> 'IF EXISTING LICENSEE! <br /> APPLICANT INFORMATION <br /> LAST NAME: Shepard FIRST NAME: Michelle MIDDLE NAME: IF <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Kaphsiung Taiwan <br /> I — <br /> DATE OF BIRTH: SSN: j ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: Pali Fang DRIVER'S LICENSE#: -� STATE LIC.ISSUED: Maryland <br /> GENDER: FEMALE Ell HEIGHT: S WEIGHT: 135 EYE COLOR: grown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Olney STATE: MD ZIP: 2083Z <br /> FORMER ADDRESS: <br /> CITY/TOWN: San Angelo STATE: ZIP: 76904 <br /> PRINT AND SIGN <br /> PRINTED NAME: Michelle F.Shepard APPLICANT/EMPLOYEE SIGNATURE. <br /> NOTARY INFORMATION <br /> On this before me,the undersigned notary public,personally appeared Michelle F.Shepard1 <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were driver's IICenSE <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 /> 1011E KLINK <br /> Notary Public•Maryland <br /> DIVISION USE ONLY Montgomery County <br /> My Commission Expires on <br /> REQUESTED BY February 14,2023 <br /> SIGNATURE of CORlsAUTHORiZED EMPLOYEE <br /> lDCIt tdenhly rhv11 Index PIN Number,�s lu be completed by(hose applicants Thal have keen issuetl an Itlenoly Theft <br /> P Number by the OCR Cl'CA agencies are rnautical to provide all applicants the opportunity to include this <br /> r....... <br /> Iw mabon to troutr the aauracy of the CORI request process ALL CORI request loans that Include This held are <br /> required to be submnled to the 001 Wa mail or by lax to 1617)66o-4619. <br />