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ADDENDUM A <br /> in <br /> 6. Chapge o ,Offiawl Stock or Ownersntp Inter st jCQn# <br /> I 1--l-1-11111........... <br /> List all proposed individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(Eg.Stockholders, <br /> Officers,,Directors,LLC Managers,LLP Partners,Trustees etc.). <br /> Entity Name Percentage of Ownership in Entity being Licensed <br /> ........... <br /> (Write"NA"if this is the entity being licensed) <br /> ................ .......... ........................ <br /> Name of Principal dress Residential Address SSN DOB <br /> .................—....... .......... ......................................................... <br /> ............ .............. ..................... <br /> Title and or Position Percenta e of Ow i Director/LLC Manager US Citizen MA Resident <br /> ............... q nersh I <br /> ...... ................... . ........ <br /> ...................... <br /> ................................. ................................................. <br /> C Yes No ("Yes ( No ( Yes ( No <br /> Name of Principal Residential Address SSN <br /> .......................................... �Wa DOB <br /> ............................................................ <br /> .................... <br /> Title and or Position Percenta of Ownnersh!«rrrrrrge ,�hi Director/LLC Manager US Citizen MA Resident <br /> .�rcrrrcr ............................�rr...... .............................................. ........................................ <br /> -—--------- C Yes ("No Yes r No C Yes C No <br /> ........... ............ ..................--... ............. <br /> .......... <br /> Name of Principal Residential Address SSN <br /> DOB <br /> ... . ........--.............. ...... <br /> F <br /> ...................-ji L...... wwwwwwwwr,www .............................. <br /> Title and or Position <br /> ............... Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> ............................... <br /> E.. ] <br /> 11:� ................. <br /> .................. C Yes C No Yes No C Yes No <br /> Name of �11-1 Principal Residential Address SSN DOB <br /> ........... ................... <br /> ...................................... <br /> 111�1�1�1�1�1�1�1�1�1�1 =-- ­­­ 11 9---------------------------------------------- <br /> Title and or Position Percentall mrcrR11 <br /> �otf Ownnwwn ers,,hi- Director/LLC Manager US Citizen <br /> ........................ MA Resident <br /> .................................... I....................................................................... <br /> �nn <br /> rrrrrrrr <br /> j! <br /> ....... ( Yes C No ( Yes ( No <br /> ............. C No <br /> Name of Principal Residential AddressR�rr SSN DOB <br /> ................. ............................ ................................................ <br /> «rrr <br /> .............................. <br /> I","—-—----------- ........................ ................................. <br /> Title and or Position PercentrrM <br /> #qq_qf_P.wntArh Director/LLC Manager US Citizen MA Resident <br /> o <br /> -—-------------- ......... <br /> ........................... . .... <br /> ........ ........................ <br /> C Yes No ( Yes C <br /> ...................................................................................... L ',..................... ...... L-111-111�111............... <br /> Name of Principal Residential Address SSN DOB <br /> .......................... 1, F- - <br /> ........................................................................----------------------------------- I. .......... .............................................. <br /> , I I I <br /> ........... ..........- .1............ <br /> Title and or Positio,n ........................ ,—Percent,a,ge,,.of Ownershif) Director/LLC Manager US Citizen <br /> .......... MA Resident <br /> I ........... <br /> ( Yes C C Yes C No <br /> —1-..... ........... L <br /> rrrrrr <br /> I' ... ........... <br /> Name of Principal Residential Address, SN <br /> ........... DOB <br /> ........................................... .... ................................................ ...... ...... <br /> ............................ <br /> .......... ---........... .....................j,;, ........... <br /> r�r <br /> Title and or Position ge of Owners Percenta hir Director/LLC Manager US Citizen MA Resident <br /> ..............................-7 , PE. <br /> .......................... .............................. <br /> Yes No ( Yes ( No C Yes No <br /> .........................;............ ................. ..... <br /> CRIMINAL HISTORY <br /> Has any,individual identified above ever been convicted of a State,Federal or Military Crime? r Yes C No <br /> If yes,attach an affidavit providing the detail's of any and all convictions. <br />