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Coininosizveafth of Afassachvsetts <br /> Alcoholic Beverages Control Connnission <br /> 239 Causeway Street,First Floor <br /> Boston,JAA 02114 <br /> DF50R4HB.60LBDBERG Kim S,G,41.NISBORO.&!;0— <br /> TR94SV'RER A.ND RECEIVER GEN'EK-IL CORI REQUEST FORM CHAIRMA.At <br /> The alcoholic Beverages Control Commission hwe been certified by the Criminal History S,,,slorns Board to access conviction and pending Criminal Offender Record <br /> Information.For the purpose of approving each shareholder.owner'licw v-,o or applicant f�r an alcahaitc beverages licemse,I understand that a criminal record check <br /> will be conducted on me,pursuant to the above The intoTmation hclok�is oormct to the best of knowledge. <br /> ABCC LICENSFINFORMA770111 <br /> APPLICANT INFORMATION <br /> rL NAME; Kurt lJohn AST NAME: Fkhnaubelt FIRST NAME., MIDDLE NAME: <br /> MAiDF.NJNA,MFE0R ALIAS(IF APPLICABLE): n/9 PLACE OF BIRTH: Ep,:sbu�rg� PA <br /> DATE OF BiRTF (D THEFT INDEX PIN(IF APPLICABLE).- <br /> N40THER*5 MAIDEN NAME, DRIVER'S LICENSE 9: STATE UC.ISSUED: <br /> EYE COLOR: <br /> MALE —7 HEIGHT: Es WEIGHT: Frey GENDER: I EO <br /> C,jRRENT ADDRESS; <br /> OTYJTOWN: [Nashville 5TATE: TN ZIF: 37203 <br /> I <br /> FO RME R ADDRESS: <br /> _71 <br /> Frisco <br /> EK <br /> STATE: ZIP, F:=1 5033 <br /> PRINT AND SIGN <br /> PRINTEDNAME: belt APPUCANTIEMPLOYEE SIGNATURE <br /> NOTARY INFORMATION <br /> On this Wjzzgo before me,the undersigned notary public,personally appeared KU.rt Schnaubelt <br /> (name 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 e)(she)signed it voluntarily for <br /> its stated purpose. <br /> .............. <br /> NOTARY <br /> Pu' <br /> S TE <br /> DWISION USE ONLY TEN <br /> NESSEE <br /> PUBLIC z, <br /> PW N.'W'D Wa 1. 1-W-MJ-4.-4 W <br />