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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 95 Fourth Street,Suite 3 <br /> Chelsea,AL4 02150 <br /> SST FORM <br /> .ff"M.LORIZ10,ESQ. <br /> CffALRMAN <br /> The. Alcoholic Beverages Control Commission ("ABCC") has been certified by the Criminal 11story 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 /> ........... <br /> AHCC LICENSE INFORMAT101V .................................... .................................... ............ ............ <br /> A13CC NUMBER: LICENSEE NAME: CITYITOWN: <br /> (IF EUSTING UCENSEE <br /> .....) <br /> ..... .... <br /> ...................... <br /> ............... ................................. <br /> APPLICANTINFOR <br /> MIDDLE NAME:AME--r <br /> LAST NAME: t-<4A k n FIRST NAME: <br /> ........ <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: <br /> ......... ........... .......... .............. <br /> DATE OF BIRTH: ;SN.- <br /> ID THEFT INDEX PIN(IF APPLICABLE): <br /> ............. ................. ....... <br /> � ► m <br /> MOTHER'S MAIDEN NAME: ,.,,!VER'S LICENSE �*,TATELIC.ISSUED: <br /> WEIG LOR., <br /> KEIGH HT: EYE CO <br /> GENDER: T: <br /> CURRENT ADDRESS: <br /> f_� ZIP: <br /> CITY TOWN: STATE: f 7 <br /> e,* <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP; <br /> ....................................... .............. <br /> PRINTAND SIGN ......................................... ............ ......................... <br /> IL � �� <br /> PRINTED NAME: �' �t <br /> APPLICANT/EMPLOYEE SI.GW<RE.- <br /> ......——---------------mmm <br /> - <br /> NOTARYINFORMATI ---—--------- ........ <br /> 0n this <br /> before me,the undersigned notary public,personally appeared <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were AM <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 /> Lt L_'L _7k <br /> NOTARY <br /> SION USE ONLY <br /> ........................ <br /> REaUFSTED BY! <br /> 15 <br /> The DCJI Ideaft Theft Index PIN Number Is to be completed by those applicants that have been Issued an Identity Theft <br /> PIN Number by the DCJI.cartifted alandes are required to provide&0 appReartu the opportunity to include Ws <br /> Informstion to ensure the a=umW of the CORI request process. ALL MR1 request forms that Indude thLs field are <br /> required to be submkud to the 001 viw mall arb fax to i S171660,46 1 4............................. ......................................__j <br /> 1 .1"1, �............, <br />