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{ 1 ' <br /> a T <br /> . It the applicant is a corporation, answer the following questions: (Corporate applicants must include with this application <br /> a copy of the Grote by the board of directors appointing the manager or other principal representative) <br /> a.Are the majority-of directors-United States itiZens? Yes ONo <br /> b.Are the majority of directors citizens of the.Co'm tonwealth of Massachusetts? 2Yes ONo <br /> ' Y <br /> . Is the manager or principal representative a United States Citizen? Yes No _ <br /> 11 <br /> d. How manor shares of stock are authorized?.,Loo e. How manor shares of stools are issued? # <br /> _f..Will any stock. be pledged as collateral for this license?` Eyes leo If yes, to whom? <br /> �A } <br /> ��c.. <br /> g. 1 iI I thi s license be p led gieu as coif at al []Yes [D'No If yes, to whom? <br /> NOTE: -if applicant is- ars association, a-copy of the birth certificate, naturalization certificate, or registered voter certificate <br /> for each member who signs'at the end of this form must be included with this application " . •,, =:: :. •" ".: <br /> _ N OTI CE <br /> The accompanying General Instructions are incorporated herein by references.. . <br /> iGN D-ASVD SUBSCRIBED TO UNDER PENALTY-OF PERJURY THIS --` DAY OF �. _-.�,..�_1 <br /> BY: IGNATURE OF FIJL.L NAME TITLE <br /> �Pt,007 ao <br /> ..�.--, .. � � � a • a � f � i � i f f i � !+y i � � r � � t r"i f r 1 f �� i�•� r I 1 ii r!I��1/I rte• I�P��ilq_Piiq•� __-_ ___ - .. -_ <br /> # rr + • � s �r � r � r r � r • rt f• � rr •� � y rt r f rt r f� i rt� r r� <br /> r �;f ; r 1 t •# � � � �r s r rr rt � rt rt � rt �� 4 r~ • • f �� �� w <br /> # t � � � r � •� rt f� f � f � r r rt � � � r r � f � •rt� f f� � • f rt r <br /> Note: 'I. Indi viduaI applicant(s) must sign above. _ <br /> . Applications by a partnership must be signed by a majority of-the partners, <br /> Appli anions by a corporation must be signed by an officer-authorized bye-a vote of the corporation's board of directors. <br /> A copy of the vote of authorization must be included with this application, <br /> - . Applications by an as sociation must besigned by a majority of the rnernbers of the goveming body. <br /> All the signers must have answered question 6a. <br /> Name of attorney, if any. filing application on behalf of licensee. 1 Telephone number <br /> Office address <br /> Time of filing Date of filing Name of nerspaper publishing notice of application <br /> F-16_ day [J7 day <br /> license granted <br /> ior <br /> Space below may be used by local licensing authorities for additional information. - <br />