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Commonwealth of Massachusetts
<br /> Alcoholic Beverages Control Commission
<br /> 239Causeway,Street,.First Floor
<br /> Boston,AM 02114
<br /> CORI RE, UEST FORM
<br /> DEBORAHB.GOLBDBERG ......... JEAN M.LORIZ10,ESQ.
<br /> TREASURER AND RECEIVER GENERAL CHAIRMAN
<br /> The .Alcoholic Beverages Control Commission ("A. CC") :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 me,pursuant
<br /> to the above.The information below is correct to the hest of my knowledge.
<br /> ARCC LICENSE INFORMATION
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<br /> ABCC ►1UN18E�t; 67000051 LICENSEE NAME: N V E BUR f i E ( UF + E (Ir�IA NA �M�NY,I CITY/TOWN: MASHPEE
<br /> (IF EXISTING LICENSEE) .......................
<br /> APPLICANT................................INFORMATION
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<br /> LAST NAME; H '!'/EF FIRST NAME* ��1� ..........
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<br /> MAIDEN NAME OR ALIAS(IF APPLICABLE). � PLACE OF BIRTH:
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<br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE);
<br /> I[�EN NAM E ..... DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts
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<br /> GENDER.[FEMAL.E HEIGHT; " ° WEIGHT: '""" EYE COLJR:
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<br /> CURRENT ADDRESS:
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<br /> FORMER ADDRESS:
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<br /> CITY/TOWN: STATE: vi yl ZIP:
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<br /> PRINT AND SIGN
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<br /> NOTARY INFORMATION
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<br /> On this 12T OF NOV, 2019before me the undersigned �
<br /> g ed notary public,personally appeared 'SUE A. HOOVER
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<br /> (name of document signer),proved to me through satisfactory evidence of identification,which were ��� t�►�1fi�L t�' L�� �
<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.
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<br /> NOT AJ 1
<br /> TAMAM VINCENTY
<br /> * TAR PUBLK:
<br /> DIVISION USE ONLY Commonwealth�of IM ssachu! f
<br /> Commission Expires
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<br /> r March t 202i
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<br /> The tell Identity Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft G
<br /> PIN Number by the DCA.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 formis that include this field are
<br /> ra;;uired to be submitted to the J7t`.�J via mail or by fax to(617)660-4514.
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