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{ <br /> Commonwealth of Massachusetts <br /> A1coho lic.beverages Control Commission <br /> 5,fourth Street,Suite <br /> Chelsea, 215 <br /> COS REOUEST FORM <br /> CKAIRMAN <br /> The Alcoholic Beverages Control Commission ""BCC r has been certified by the Criminal History Systems Board to access <br /> conviction and pending Criminal +offender Record nformation ('"CORV . or the purpose cif approvin each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criminal record check will he conducted on me,pursuant <br /> to the above.The information below is correct to the hest of my knowledge. <br /> e. <br /> ABCC LICENSE INFORMATION <br /> ABCC NUMBER: LICENSEE NAME.I' CITY/TOWN., Mashp�ee <br /> I�,llanl,Inc. <br /> (IF EXISTING LICENSEE) <br /> APP'L1C'A 'TINFORMATIO <br /> LAST NAME: Agge,rbeck FIRST NAME. Pamela MIDDLE NAME. Sue <br /> MAIDEN NAME CAR ALIAS(IF APPLICABLE). Gianettino PLACE OF BIRTH: Zanesville,Ohio <br /> DATE OF BIRTH. SSN: III THEFT INNER{PIN(IF APPLICABLE). <br /> MOTHER'S MAIDEN NAME: Bennett DRIVER'S LICENSE#t: STATE LIC.ISSUED: Massachusetts <br /> WEIGHT. .40 EYE COLOR: Hazel <br /> GENDER: FEMALE HEIGHT: <br /> CURRENT ADDRESS, <br /> CITY/TOWN. Mash pee STATE.: MA ZIP: 1102649 <br /> FORMER ADDRESS. <br /> CITY/TOWN: STATE. ZIP: <br /> PRINTAND SIG <br /> PRINTED NAME: Pamela S Agge,r'beckAPPLICANT/EMPLOYEE SIGNATURE: r6' <br /> NOTARY INFORMATION <br /> On this heave me,the undersignedsundersignednotary public,personally appeared Pamel <br /> a S Aggerbeck <br /> name of document i ner,proved to me through satisfactory,evidence of identification,which were <br /> CeA- <br /> to be the person whose name is signed on the preceding or attached document,and knov�iedged o me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> ES ANDS <br /> NotarY Public <br /> wealth of Mass8chus0ft <br /> Gommon NOTARY <br /> co <br /> lbeM22'rArA'MY <br /> mmissio ' <br /> DIVISION USE ONLY <br /> RECILi'E5"Tli=D Y: <br /> SIGNATURE OFCf7fil-AUTHORI E Em LoYEE <br /> The DCil Identify Theft Index PIN Number Is to be completed by those applicants that have been'issued an Identity Theft <br /> PIN Number by the DCli.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 forams that include this field are <br /> required to be submitted to the DCII via snail or by fax to(617)660.4614. <br />