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Commonwealth of Massachusetts
<br /> � � Alcoholic Beverages Control Commission
<br /> .. 239 Causeway Street,First Floc
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<br /> DEBORAH B.GOLBDBER G .. E UEST F
<br /> TREASURER AND RECEIVER GENERA
<br /> The Alcoholic Beverages Control Commission "ABCC") 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 can me,pursuant
<br /> to the above.The information below is correct to the best of my knowledge.
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<br /> ABCC LICE'N'SF INFORMATION
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<br /> � "��AJ �� J ���MANAGEMENT,NUMBER: 00 LICENSEE ( �� � �N'. ■ �
<br /> it EXISTING LICENSEE)
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<br /> APP"LICANTINF R ATI
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<br /> LAST NAME: HOOVER FIRST NAME: SUE MIDDLE NAME:
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<br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): .. .... � �P PLACE OF BIRTH:
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<br /> DATE OF BIRTH: SSN: ICE THEFT INDEX PIN(IF A,PPLICABLE):
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<br /> MOTHER'S MAIDEN lAI'►IIE: T' , 4avvx DRIVER'S LICENSE#: STATE LIC.ISSUED: ssachU efts
<br /> GENDER:�FEMALE HEIGHT: 7 WEIGHT: I �� EYE COLOR:
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<br /> CURRENT ADDRESS:
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<br /> CITY/TOWN: �DUXBURY
<br /> STATE: MA ZI R: �0
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<br /> FORMER ADDRESS:
<br /> CITY/TOWN: STATE: ZIP:tc
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<br /> PRINTANDSIGN
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<br /> IF
<br /> RINTE NAME: SUE A. HOOVERAPPEICAN'T E M PLOYEE SIGNATURE:
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<br /> NOTA
<br /> .....rr.. .......m. ...._. �__.. ..—On this 12TH OF NOV 2019
<br /> before e, undersigned rota lippersonally . HOOVER
<br /> � appeared ra
<br /> (narne of document signer), roved tome through satisfactoryevidence of identification,which were PERSONAL KNOWLEDGE
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<br /> to the person whose name is signed ors the preceding or, ae a ,and acknowledged to me that(he) s signed it voluntarily to
<br /> its stated purpose.
<br /> Ar
<br /> NOTARY....
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<br /> NOTARY PUBLIC
<br /> My Commission ExPires
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<br /> DIVISION USE ONLY March 5j l
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<br /> REQUE sTED BY., m
<br /> The 0CJI Id+enVfy"theft Index Plpt N,ijrr�,er'ls to be rompleted by those apphanb that have been ISSLre.1A an Identity Theft
<br /> PIN plumber by the DCJI.Certffrecl agenc+es are required to provWe all applicants the apportunfty to rnclr�de thls
<br /> Worrnatlon to ensure the accurary 0 the C I request process. ALL CORI request forms that'include this field arre
<br /> required to be submitted to the r3C:,`I ifa mash or by foot to 1617)660-461+4.
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