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ADDENDUM A <br /> .6, Ch e of Offe <br /> I C.......... _�,ock or Own ershi,p,,!,nte rest ( e d <br /> ............... ........ _�pntinu <br /> List all proposed individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(E.g.Stockholders, <br /> Officers,Directors,LLC Managers,LLP Partners,Trustees etc.). <br /> Entity Nara 11�1 e Percentage of Ownership in Entity being Licensed <br /> (Write"NA"if this is the entity being licemsed) <br /> ............................ <br /> ...........- <br /> ............. <br /> ............... <br /> Name of Principal Residential Address SSN DOB <br /> L ........... ..................... ...........-—--—---------- .................... ..................... ... . ...................................---—------------- <br /> .......... <br /> Title and or Position <br /> Percentage of Ow <br /> ner <br /> ........ .................. Director/LLC Manager US Citizen MA Resident <br /> ................... C'Yes No IC,Yes No C.Yes <br /> No <br /> IName of Principal Res ide ntial Address <br /> SSN DOB <br /> .........................-­-­................. .................................................. .......... ......... ............................ <br /> .......... 1-1111111111111"'........ .................... <br /> "",""',.......... <br /> Title and or Position <br /> ........... _Percenta,qeof Ownershi Director/LLC Manager US Citizen MA Resident <br /> r... ....... 7 � ............... ........................ <br /> ................. ("Yes C No <br /> ........ mmmry ( Yes ( No <br /> ................. -—..............- I <br /> Name of-Principa.1,............................... .......... Residential Address 5SN <br /> .......---—-------------------- DOB <br /> -—----------- <br /> ........... <br /> Title and or P osition Percent��q�,qfOwnershi. Director/LLC Manager US Citizen MA Resident <br /> ....................... <br /> ................................ I-........................ <br /> Name of Principal Residential Address <br /> .................. SSN DOB <br /> ............. <br /> ........................................................... ............ ................. <br /> Title and or Position ---Percen�tajce of Ownersh",, Director/LLC Managers Citizen MA Resident <br /> .................... <br /> ............ ............. <br /> ............. .mmm ( Yes ( No C Yes C No <br /> E <br /> ....................... ...... <br /> Name of Principal Residential Address SSN DOB <br /> ........... ....... ...........---........... <br /> ...........X <br /> -—-------- ................ <br /> Title and or Position .............................. Percentaqt of Ownershi Citizen MA Resident <br /> .......... . ............ n Director/LLC Manager US Cit* <br /> ..............Yes........ ................................ ( Yes ( No Yes No <br /> Name of Principal Residential Address S S N DOB ......................... <br /> ................-.-- -1.......................................,.................................................................l ................................................. .......... <br /> E" or Position PercntaLfq �h Director/LLC ......... <br /> ..Manager. .U..................S......... <br /> Citizen.................—.....................-....-­-- ...... <br /> .e.......idTitle nt <br /> ....——--------------- <br /> ............... C Yes C No r Yes No ( Yes ( No <br /> Name of Principal Residential Address S SN D"1 0 11 B <br /> ...... ..... ...................... <br /> ........................................... .........--­­..................... <br /> ........................................................................ ............ <br /> ................... <br /> Title and or Position Percentage of Ownershi,n Director/LLC Manager US Citizen MA Resident <br /> ......................... <br /> ........ .............................. .......................... .................... <br /> .................. ................ r Yes r No C <br /> L-r Yes No <br /> ................ ....... <br /> CRIMINAL HISTORY <br /> .......................... <br /> ............................ <br /> Has any individual identified above ever been convicted of a State,Federal or Military Crime? ("Yes C No <br /> If yes,attach an affida'vit providing the details of any and all convictions. <br />