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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 95 Fourth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JEAN M.LORIZM ESQ. CORI REOUEST FORM <br /> CHAI"AN <br /> The Alcoholic Beverages, Control Commission ""A CC"" 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: LICENSEE NAME: Magni Inc. CITY/TOWN: Mashpee <br /> (IF EXISTING LICENSEE) <br /> APPLICANTINFORMATION <br /> LAST NAME: Aggerbeck FIRST NAME: Jan MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Glostrup,Denmark <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: Varberg DRIVER'S LICENSE#: STATE LI C.ISSUED: Massachusetts <br /> WEIGHT. 205 EYE COLOR', Blue <br /> GENDER: MALE HEIGHT: 6 <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Mashpee STATE. MA Z1 P, 02649 <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP: <br /> PRINTAND SIG <br /> N <br /> PRINTED NAME: Jan Aggerbecl< I APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMA'TION ------ <br /> On this before me,the undersigned notary public,personally appeared Jan Aggerbeck <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were \C'u,5 <br /> to be the person whose name is signed on the preceding or attached document,and knowledged to me that(he) (she)signed it voluntarily for! <br /> its stated purpose. <br /> JAMES AN <br /> Notary Public NOTARY <br /> My Commission Expires November2l <br /> DIVISION USE ONLY <br /> REQUESTED BY: I SIGNATURE UP CMI-AUDIGIRIZED EMPLOYEE J <br /> The DC identity Theft Index PIN Number is to be completed by those applicants that have been issued an,identity Theft <br /> PIN Number by the DCJI,Certified agencies are required to provide all applicants the opportunity to include this <br /> Information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are <br /> required to be submitted to the DCJI via mail or by fax to 1617)660-4614, <br />