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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,.First Floor <br /> X Boston,AIAt.02114 <br /> • K <br /> r <br /> v <br /> LORI REQUEST FVFORM.UERCI.RA.H B.GIfI.LBDRERG TEANIVI'.LORIZIO,ESQ. <br /> TREASURER AND RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("ABCC") has been certified by the Crinunal History Systems Board to access <br /> conviction and pending Criminal Offender Record Information ("CCRI"). 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: 67000071 LICENSEE NAME:Commons Convenience,Inc. CITY/TOWN: Mashpee <br /> (IF EXIMNG LICENSEE) <br /> APPLICANT INFORMA TION <br /> LAST NAME: Chaudhry FIRST NAME: Saeed MIDDLE NAME: Anwar <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: <br /> DATE OF BIRTH-, SSN: ID THEFT INDEX PtN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVERS LICENSE#: STATE LIC,ISSUED: Massachusetts <br /> GENDER: MALE F, HEIGHT: 5 �r# g �r' <br /> WEIGHT. 170 EYE COLOR: Black <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: 02563 <br /> FORMER ADDRESS: <br /> CITY/TOWN: Hyannis STATE: MA ZIP: 02601 <br /> PRINT AND SIGN <br /> PRINTED NAME: Saeed A.Chaudhry APPLICANT/EMPLOYEE SIGNATURE: <br /> NO TAR-Y INFORMATION <br /> On this c before me,the undersigned notary public,personally appeared Saeed A.Chaudhry <br /> (name of document signer),proved to me through satisfactory evidence of identification,which wereMA Drivers License <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 /> 9 <br /> .. •a- * CA <br /> DIVISION USE ONLY <br /> Ilk <br /> REQUEMD BY: <br /> SIGNATURE OF C'OM-AUTHORIZED EMPLOYEE Irl 0,.•`;I'�r'Y 0 C�1 <br /> The❑CJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft �1 'Pfi�j�►�� � <br /> P€h'Number by the Dol.Certified agencies are required to provide ali applicants the opportunity to Include this / 'i►�• t6vN <br /> ,1 <br /> information to ensure the accuracy of the COW request process.. ALL CORI request forms that Include this field are �C�t �� <br /> required to be submitted to the CCI{via mail or by fax to(617)66"614. <br />