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4\ Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> Boston,MA 02114 <br /> DEBORAHB.GOLDBERG <br /> LORI REQUEST FORM JEANM.LORIZIo,ESQ- <br /> TREAr UIffR 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 /> ABCC NUMBER: LICENSEE NAME:ASZS Group,Inc. C1TY/TOWN: Mashpee,MA <br /> (fF IXISTING IJCENSEEI -- <br /> APPLICANTINFORMATION <br /> LAST NAME: Shahid FIRST NAME: Zohaib MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): W PLACE OF BIRTH: <br /> DATE OF BIRTH: SSN: I ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME- �� DRIVER'S LICENSE B: STATE LIC.ISSUED: Massachusetts <br /> GENDER: HEIGHT: WEIGHT: EYE COLOR: <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: <br /> 3 <br /> FORMER ADDRESS: <br /> CITY[TOWN: STATE:= ZIP: ^ <br /> PRINTAND SIGN <br /> PRINTED NAME: Zohalb Shahid APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARYINFORMATION <br /> On this [ re me,the undersigned notary public,personally appeared Zohaib Shahid <br /> (name of document signer),proved tome through satisfactory evidence of identification,which were t&"&, &Ijl� <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to a that(he)(she)signed It voluntarily for <br /> its stated purpose. <br /> N07A <br /> '���Q�.�`1\202?�RF�;• �� <br /> DIVISION USE ONLY <br /> i <br /> cb *v ,.'0 <br /> REQUEMD 6y: <br /> `' {� <br /> 'the OCIF Identify Theft laden PIN Numher Is to he evmpkled dy those appllanis that BovehEro Issued an ldentNy Thele /f��/,, ,V0TAR` <br /> PIN Numbu by the"CII.Certified agenda en mpind to proWde all aPplt..ts the oppartWty to lod++de this � � <br /> information to enure the auvnay of the CORI request pmoo ALL CQRI mqumt fomes that tnriude this"eid on /�0/1111111"IN \ <br /> m9ulmd to he submitted[o the SCR Wo..It or by fax to{6171659-4614. <br />