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ADDENDUM <br /> 6. PROPOSED OFFICER?, STOCK WNE SHIP INTEREST <br /> ,beneficial or financial interest List all individuals or entities that will have a direct car indirect in this license .E <br /> � g Stockholders,Officers, <br /> Directors,LLC Managers,LLP Partners,Trustees etc.). <br /> Entity Dame Percentage of Ownership in Entity being Licensed <br /> . <br /> (Write "NA"if this is the entity being licensed) <br /> !i <br /> 1 jl� <br /> s <br /> � � 1 <br /> Name of Principal 'Residential Address SSI I DOB <br /> AA <br /> Title and or Position Percents <br /> . . e of Ownersh Director/LLC Manager US Citizen MA Resident <br /> ,.n �� <br /> w r <br /> .mmmmw <br /> a««««« c Yes C� o � ''""` n <br /> ......�,�,,,,,,,,,,,,, Yes <br /> Marne of Principal Residential Address 55�1 <br /> DOB <br /> m� <br /> Title an can Percenta�e of twnershi Director/LLC Manager US Citizen <br /> d_p►r P�siti � , � A Resident <br /> �� � mm�mmmmm <br /> Yes o, Yes r t� Yes "- Icy <br /> 'ar-ne of Principal 'dential Address SSN <br /> 1:1i---,,,— I <br /> rrr ����� r� <br /> Resr DOB <br /> ........................................... <br /> a <br /> Position Percent � e of Ownershi I Director/LLC Manager US Citizen <br /> Title ands................................................................ �.� .�.,. «««« .____-�.,...�, ....... ................ <br /> MA Resident ....................... <br /> �m=No <br /> Yes " NCB ." Yes ` No `Yes <br /> Name of Principal............... Residential Address SSA! DOB..........��i <br /> ............................................................... <br /> �m <br /> m le and or P ► ition Percentage of Ownershi Director/LLC Manager US Citizen ` <br /> Tit �n ....�_,,,M��mm�vv�uuu MA Resident s dent <br /> Yes "` No '"' Yes """ c ( Yes o <br /> ammmmmmmmmmm m �.� � <br /> Name of Principal 'Residential Address SSA DOB <br /> ..........��..��.. ........ <br /> F <br /> .............. ............................................. <br /> w �������� �n�n�n�nn �www <br /> Tale and orPosi Position Percentage of+ wnershi, Director/LLC Manager,US Citizen <br /> mmm .� MA Resident <br /> � <br /> `Yes C"'No "` Yes Yes ` o <br /> Name of Principal Residential Address SSI�J <br /> DOB <br /> y .......« �w �� �m� �.mmmm <br /> Title and or Position Percentar e cif Ownershi Director/LLC Marra er US Citizen <br /> m�m g MA Resident <br /> No <br /> ( Yes No <br /> No ( Yes <br /> Name of Principal Residential Address SS�I <br /> DOB <br /> Title and or Position Percenta e of Ownershi.' Director/LLC Manager US Citizen MA Resident <br /> a� <br /> '"` Yes '` oEC' Yes ':N:oj <br /> IMI AL HISTORY <br /> ..................... <br /> Has any individual identified,above ever been convicted of a State,Federal or Military Crime? <br /> mm <br /> If yes,attach an affidavit providing the details of any and,all convictions. <br />