Laserfiche WebLink
Commonwealth of Massachusetts <br /> a" r' <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> Boston,AM 02114 <br /> J <br /> J , <br /> r <br /> �-�t �. <br /> 1. ORI REQUEST S T FORM <br /> DEBOR"B.GOLBDBERG JEAN.M:LORIZIO,ESQ. <br /> TREASURER AND.RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("ABCC") 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 f <br /> ABCC NUMBER: LICENSEE NAME:Mew CITY/TOWN: filedS t p e <br /> OF EXX"NCx LICENSEE) <br /> A PP L I CA N T IN FO RMA TI L]N <br /> F <br /> LAST NAME: Mullen FIRST NAME: Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OIL BIRTH: <br /> z <br /> DATE OF BIRTH: l SSN: 3 ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE M STATE LIC.ISSUED: Massachusetts <br /> 1 <br /> GENDER: MALE HEIGHT: WEIGHT: EYE COLOR: Brown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: r - <br /> FORMER ADDRESS: <br /> - -------_ --- <br /> CITY/TOWN: STATE: MA ZIP: i <br /> PRINTAND SIGN <br /> PRINTED NAME: ,,/k APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> 3 <br /> 1 <br /> Can this ` before me,the undersigned notary public,personally appeared4*1 <br /> - <br /> (name of document signer), roved 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(he)(she)49ned It voluntarily for <br /> i <br /> Its stated purpose. <br /> �� J%y <br /> f <br /> NOTARY { <br /> TAMARA VINCEW JOYa <br /> NQTARY PUBLIC <br /> Commonwealth of Massachusetts <br /> DIVISION[1SFONL t My Commission Expires <br /> March 5, 2021 <br /> REQUESTED BY: <br /> ,z <br /> SIGNATUA OFCORI-AUTHORIZCDEhIPLOM <br /> The vcll Identify Theft Index PIN Number Is to be completed by those applicants that have been Issued an ldentttyTheft <br /> PIN Number by the.pvl.Certified agancles 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 farms that include this Mild are <br /> required to be submitted to the licit via mall or by fax to(6171660.4614. <br />