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MANAGER APPLICATION <br /> A. MANAGER INFORMATION <br /> IATIc N <br /> The individual that has been appointed to manage andcontrol the licensed business and premises. <br /> Proposed Manager Name Jan Aggerbeck Date of Birth SSN r <br /> Residential Address Mashpee ILIA 02649 <br /> Email Phone , <br /> Please Indicate how many hours per week you intend to be on the licensed premises 4 <br /> B.CITIZEN SH I PLBAQ ROUND INFORMATION <br /> Are you a U.S.Citizen? ('o Yes No *Manager must be a U.S.Citizen <br /> If yes,attach one of the following as proof of citizenship US Passport,Voter's Certificate,Birth Certificate or Naturalization Papers. <br /> Have you ever been convicted of a state,federal,or military crime? C"des No <br /> convictions.Attach additional pages,i necessary, <br /> l�`yes, Nil out the table below and attach an affidavit pravwd�in the details of any and all c <br /> utilizing the format below. <br /> Late Municipality Charge Disposition <br /> C.EMPLOYMENT INFORMATION <br /> Please provide your employment history.Attach additional pages,if necessary,utilizing the format below. <br /> Start Cate End Date Position Employer Supervisor Name <br /> Manager <br /> er Ma <br /> �,/ 111 current g ni Inc. NA� <br /> e <br /> Chi.PRIOR DISCIPLINARY ACTION <br /> Have you held a beneficial or financial interest in,or been the manager of,a license to sell alcoholic beverages that was subject to <br /> disciplinary action? C yes No If yes,please i�ll out the table.Attach additional pages,if necessary,util!zing the format below. <br /> Cate of Action Marne of License state city Reason for suspension,revocation or cancellation <br /> I hereby swear under the pains and Jes a 'perjury that th ` '06rmation have provided in this application is true and accurate: <br /> Manager's signature Date <br />