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ADDENDU,,,M1 A <br /> changp of offic <br /> ers,_g or Ownershl "nteres <br /> ............ ................. <br /> t-fContinued..., <br /> List all proposed individuals or entities that will have a direct or indirect,beneficial or financial interest in this 11cense'(E.g.Stockholders, <br /> Officers,Directors,LLC Managers,LIP 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 Residential Ad dress D 0 B <br /> .......... ............................................ <br /> ......................... <br /> ................... .......... .............. ............................... ............. ...... <br /> Title and or Position <br /> .......................... Percenta e of Ownershill Director/LLC Manager US Citizen MA Resident <br /> C;Yes No <br /> P <br /> ............ C Yes No <br /> .............. <br /> Name of Principal ....................................................... ..... <br /> Residential Address SSN DOB ................................................................... <br /> "I.................... ................. <br /> -—---------------..................................... ............................................... ..................... <br /> [................... ........... <br /> m. <br /> Title and or Position <br /> Percenta f Owner hi Director/LLC Manager <br /> s IP nage US Citizen MAR esident <br /> Yes C No <br /> ................... .............. WmrrN ( Yes ( No <br /> ......................... <br /> Name of Principal <br /> Residential Address SSN <br /> DOB <br /> ------------- <br /> ........ <br /> 11-...........J ..........—­­.................... .................. <br /> Title and or Poon I ............ ........... .................. <br /> .......... ..........­ ——------- Percenta�g�Ownership Director/LLC Manager US Citizen MA Resident <br /> ............. <br /> ..........................-—----------------- .................. <br /> .......... ........ Yes C No C' Yes C No ( Yes ( No <br /> Name of Principal Residential Address I............................................... —,I <br /> SSN DOB <br /> .............................. .......... ......... <br /> Title and or Position rcent............... Pe �.qft of Ownersh[p Director/LLC Manager US Citizen MA Resident <br /> ( Yes <br /> Ye C Yes No <br /> Name of Principal Residential Address <br /> ....... ............... SSN DOB <br /> E <br /> ........................ <br /> Title and or Position ................................................... <br /> ........... Pe ,qentaq_q of OWn,��ft, Director/LLC Manager US Citizen MA Resident <br /> ................ <br /> ........... -—----—-------- ( Yes No C Yes No 0 <br /> ( Yes N <br /> .......... <br /> Name of Principal rrrrrrrr---——----------------- Residential Address SSN DOB <br /> ................................ .................. <br /> ................. ... ........... <br /> .............. <br /> L............. ............ ........... �� �m�,..�.. n���„mom <br /> Title and or Position Percpnt ——-------- <br /> tflta Manager US Citizen MA Resident <br /> A,,,,,e of Ownershl" Director/LLC <br /> .............. ................ <br /> .....——----------- <br /> ............. C No Yes C No <br /> ............................-­-"'-'­................... ........... C Yes No <br /> Name of Principal . ..................................... <br /> Residential Address ......` <br /> ......................... ................ SSN DOB <br /> ............. ............. <br /> .......... .................. ................................................................................... ...... .................... <br /> Title and or Position <br /> ......... ......... Percentarae of Ownershl Director/LLC Manager US Cit4 <br /> ................. ..................... ............ rvrvry izen MA Resident <br /> ........................... ( Yes, ( No r Yes No ( Yes ( No <br /> .......... .................... <br /> CRI AL HISTORY <br /> ............................................ <br /> Has any individual identified above,ever been convicted of a State,,Federal or Military Crime? No <br /> If Yes,attach an affidavit providing the detail's of any and all convictions. .......... <br />