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P4.m\ o monwealth ofMassachusetts <br /> Alcoholic Beverages Control Commission <br /> 5.Fourth Street,Suite <br /> Chelsea,AAA 02150 <br /> UU-M .InQUEST FQRM <br /> JEAN M.LORIZ10,ESQ. <br /> CHAIRMAN <br /> The .alcoholic ;beverages Control Commission ("A BCC") has been certified by the Criminal history 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 one,pursuant <br /> to the above.The information.below is correct to the best of my knowledge. <br /> ASCC LICENSE INFORMATION <br /> ABCC NUMBER: LICENSEE NAME: CIT'�/To1NN: �r <br /> �(IF EXISI'INGLICEiVSEE) ........ <br /> ............. <br /> APPLICANT INFORMATION <br /> [LAST NAME: 4L '� FIRST NAME: � MIDDLE NAME: T <br /> �" L..•�► �� <br /> �����v »»»» .. .. _—-.,..,..- "klr:- <br /> MAIDEN NAME CAR ALIAS(IF APPLICABLE): I PLACE F.BIRTH: <br /> ...... I ml Ar <br /> F <br /> --- r-----� <br /> ................ <br /> GATE OF BIRTH: ,��_ <br /> n <br /> �_.... ID THEFT INDEX PIN(IF APPLICABLE). <br /> __ _... mnnnm <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: <br /> GENDER: """ HEIGHT. WEIGHT: EYE COLOR: <br /> Ell E <br /> ✓ wry <br /> '':` <br /> CURRENT ADDRESS: <br /> ., <br /> CITY/TOWN: STATE: ZIP: <br /> 1 <br /> FORMER ADDRESS: L <br /> CITY/TOWN: STATE: ZIP: <br /> ........... <br /> YMA <br /> .................... ............ <br /> PR►NTAND SIGN <br /> Fomi �PRINTED NAME: mcw5a%3APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> n this . <br /> before me,the undersigned notary public,personally appeared <br /> ._.... _ . <br /> ............ <br /> (name of document signer),proved to me through satisfactory evidence of identification,which wereL*V� '+ <br /> ............. <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he) (she)signe it voluntarily for <br /> F its stated purpose. <br /> . mmmmm.m aw <br /> m <br /> NOTARY <br /> Notary Public <br /> KEV <br /> COMMONWEALTH OF MASSACHUS <br /> My Commission Expires <br /> January 20, 2023 <br /> !�I V1.5! N USE C�NL Y <br /> REQUESTED 6Y.. <br /> .....: ......... .. <br /> The DCJI Identify Theft Index PIN plumber is to be completed by those applicants that have been issued an Identity Theft <br /> PIN Number by the t ell.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 DCJI via mall or by fax to(617)66 6 . <br />