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ADDENDUM A <br /> 6, PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST (Continued.00) <br /> List all individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(E.g.Stockholders,Officers, <br /> Directors,LLC Managers,LLP Partners,Trustees etc.). <br /> Entity Name Percentage of Ownership in Entity being Licensed <br /> (Write"NA"if this is the entity being licensed) <br /> Name of Principal Residential Address S,SN DOB <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Yes No Yes C No Yes C No <br /> Name of Principal Residential Address <br /> SSN DOB <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> Yes C No C Yes N o Yes No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percen,taqe of Ownershi Director/LLC Manager US Citizen MA Resident <br /> '7 Yes No ("Yes ( No Yes C No <br /> Name of Principal Residential Address SSN DOB <br /> I L <br /> Title and or Position Percents of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Yes (,' No C Yes C No C Yes No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> C Yes No r Yes C No ( Yes ( No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percentaqe,of Ownershi Director/LLC Manager US Citizen MA Resident <br /> C Yes C No Lr Yes Nes <br /> —j C No C Yes, C No <br /> Name of Principal Residential Address SSN DOB <br /> Title,and or Position Percents oaf Ownership Director/LLC Manager US Citizen MA'Resident <br /> Yes C No ( Yes ( No Yes ( No <br /> CRIMINAL HISTORY <br /> Has any individual identified above ever been convicted of a State,Federal or Military Crime? Yes No <br /> If yes,attach an affidavit providing the details of any and all convictions. <br />