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Commonwealth of Massachusetts <br /> w� Alcoholic Beverages Control Commission <br /> _ 239 Causeway Street,.first Floor <br /> Boston,M.02114 <br /> CA,,-1, <br /> - <br /> DBBORAHB.GOLBDB.ERG CORI REQUEST FORM JEAN.M.LORIZIQ,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 <br /> i <br /> + LICENSEE NAME: , sOWN:ABCC NUMBER IV lo-, I, <br /> (IF EXISTING LICENSEE) <br /> A PPS ICA N T INFORIVIA TI oN <br /> LAST NAME: Mullen FIRST NAME: Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> L <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> GENDER: MALE HEIGHT: I <br /> WEIGHT: EYE COLOR: Brawn <br /> CURRENT ADDRESS: i <br /> CITY/TOWN: STATE: r ZI P: r <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP: <br /> PRiNrAND SIGN <br /> PRINTED NAME: APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARYINFORMA 'ION <br /> On this r � � , �. before me,the undersigned notary public,personally appeared �,t <br /> t� q �i <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)signed it voluntarily for <br /> Its stated purpose. <br /> NOTARY <br /> its TWAM MNCENT JOYCE <br /> NOTARY PuBuc <br /> DIVISION USE O L Commonwealths of McIssachuse"S <br /> My Com Ission ExpI res <br /> REQUESTED BY., MarcT 5, 2021 <br /> 5 G R IVAEOFCOR O —D EM PLOYE <br /> The 001ldentify Theft Index PIN Number is to be completed by those applicants that have been Issued an Identity Than <br /> PIN Number by the DGI.Ge IRed 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 roans that include this field are <br /> required to be submitted to the DCII.via mail or by fax to(07I 660-46K <br />