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r <br /> Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> { <br /> Boston,MA 021.14 <br /> STEVEN GROSSMAN- IaM S.GAINSBORO,ESQ. <br /> TREASURER AND RECEIVER GENERAL CORI REQUEST FORM CHAIRMAN <br /> The Alcoholic Beverages Control Commission has been certif ed by the Criminal History Systems Board to access conviction and pending Criminal Offender Record <br /> Information.For the purpose of approving each shareholder,owner,licensee or applicant for an alcoholic beverages license,I understand that a criminal record check <br /> will be conducted on me,pursuant to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE INFORMATION <br /> ABCC NUMBER: 6700007. LICENSEE NAME: Commons Convenience,Inc. CITY/TOWN: Mashpee <br /> IIF EXISTING UCENSEI:) <br /> APPLICANT INFORMATION <br /> LAST NAME: Rasool FIRST NAME: Ghulam MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> GENDER: MALE HEIGHT: 5 g WEIGHT: 170 EYE COLOR; Black <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: 02632 <br /> FORMER ADDRESS: <br /> CITY/TOWN: Hyannis STATE: MA ZIP; 02601 <br /> PRINT AND SIGN <br /> PRINTED NAME: gHULAM rASOOL APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> On this jW before me,the undersigned notary public,p Y pp personally appeared Ghulam Rasool <br /> (name of document signer),proved to me through satisfactory-evidence of identification,which were C01LNr <br /> to be the person whose name is signed on the preceding or attached document,and knowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. V t <br /> JENNIFER M.DA CRUZ 0 Nk 'A OA4T' <br /> �► <br /> Notary Public <br /> � NOTARY <br /> Massachusetts <br /> My Commission Expires <br /> Dec 14,2023 <br /> DIVISION USE ONLY <br /> REQUESTED BY: <br /> SIGNATURE OF CDRMUMORIZED EMPLOYEE <br /> The DCII Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft <br /> PIN Number by the DCII.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 forms that Include this field are <br /> required to be submitted to the DCII via mall or by fax to(617)654-4514. <br />