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'10., MANAGER APPLICATI ON <br /> A. MANAGER INFORMATION <br /> The individual that has been appointed to manage and control the licensed business and premises. <br /> Proposed Manager Name Stephanie M.K.Raine Date of Birth SSN <br /> ........... ....... <br /> Residential Address <br /> .............. <br /> Email Phone <br /> ----------------- <br /> Please indicate how many hours per week you intend to be on the licensed premises 4 0 <br /> B.CITIZEN 5HIS LRACKGRQ_Vk INFORMATION <br /> Are you a U.S.Citizen?* ro Yes C No *Manager must be a U.S.Citizen <br /> If yes,attach one of the following as proof of citizenship US Passport,Voter's Certificate,Birth Certificate or Naturalization Papers. <br /> Have you ever been convicted o'f a state,federal,or military crime? ('Yes C No <br /> If yes,fill out the table below and attach an affidavit providing the details of any and all convictions.Attach additional pages,if necessary, <br /> utilizing the format below. <br /> Date Municipality Charge Disposition <br /> 7/25/08 Deaver,CO Driving while ability impaired Pled gull Ity,probation lapsed with no further action <br /> ------------------- <br /> C.EMPLOYMENT INFORMATION <br /> Please provide your employment history.Attach additional pages,if necessary,utilizing the format below. <br /> —7- -- <br /> mmm <br /> :It::ar:t Date End Date Position— .................... Employer Supervisor Name <br /> 8/1/19 JCurr Current Director of Program Operatio�.......... V2 Incentives Angela Wagner <br /> .................................D.PRIOR DISCIPLINARY ACTION <br /> Have you held a beneficial or financial interest in,or been the manager of,a license to sell alcoholic beverages that was subject to <br /> disciplinary action? r Yes Cis No If yes,please fill out the table.Attach additional pages,if necessaryutilizing the format below. <br /> Date of Action Name of License State City Reason for suspension,revocation or cancellation <br /> - -- '— <br /> mmmm <br /> .......... <br /> .......... <br /> I hereby swear under the pains,and penalties of perjury that the information I have provided in this application is true and accurate: <br /> .... ................. <br /> Manager's Signature Date U <br /> .......... .......................................... ............. ........ ........................ ........................... I....... <br /> ................. <br />