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ADDENDUM ENDU A
<br /> ..a 'cr r orrrl Interest
<br /> -(Continu
<br /> 6. Chan
<br /> offs
<br /> ««««<
<br /> List all proposed individuals or entities that will have a direct or indirect,beneficial or fins^racial,interest in this license(E.g.Stockholders,
<br /> Officers,Directors,LLC Managers,LLP Partners,Trustees etc.).
<br /> Entity Marne Percentage of Ownership in Entity being Licensed
<br /> (write"IAA"if this is the entity being licensed)
<br /> Name of Principal Residential Address S i DOB
<br /> n._
<br /> wo�, m ..............................................................---------.. ......................
<br /> .-..--- .................
<br /> Title and or Position Percenta of Ownerships Director/LLC Manager IDS Citizen
<br /> C Yes C o �""""'des C No C Ye,s
<br /> �.._�nm "I
<br /> ............
<br /> ip Residential rn
<br /> l Address L,_1............——---------
<br /> SS I DOB
<br /> .......... .......................
<br /> Larne of Prince
<br /> m» � tral
<br /> ...............
<br /> ..
<br /> n.
<br /> ....................
<br /> ,.r„������ �rru��
<br /> ................
<br /> ------------
<br /> `Title and or position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident
<br /> � dent
<br /> """`Yes Jo ( Yes
<br /> ���n � oI (' Yes �
<br /> —IJ
<br /> Name Principal Residential Address S, DOB
<br /> �......� ► Position
<br /> �hi�� Director/LLC Manager US Citizen i
<br /> Tmitle and r.��'��� . � MA P�rcent,a e of owners
<br /> m Yes o `` Yes C o
<br /> Yes o
<br /> ���_ es���,„ ,,,_::.M�,.r� ���.
<br /> Name of Principal
<br /> Residential Address SI DOB
<br /> .........« ��mm �,, ........... -
<br /> Title
<br /> and or P"osition P�erc �nt,a e of Ownership Director/LLC Manager per S CitizenResident
<br /> ....... ������,, �«««« � g �►
<br /> .................................................�_ ,n„ «,,,,,,
<br /> ..................
<br /> ` Yes o `Yes " fro Yes o
<br /> ..............
<br /> Name of Principal ——------- Residential Address............................................... [3tB
<br /> -----
<br /> Title and or Position g` � Director/LLC Manager US Citizen
<br /> �:R:����,,r����� Percents e of twnersh� � g MA Resident
<br /> n
<br /> _ .. Yes C No Yves �'" es �~ o
<br /> o Y
<br /> ...........
<br /> ��,,,m: .��rmmn m� . ........
<br /> Name of Principal Residential Address SSA DOB
<br /> .... �. L ,�
<br /> Title an r Position t vrnershi Director/LLC Manager Citizen
<br /> �. d o� �... ��..��. .......�r»�����, ...: .....� � n M Resident
<br /> «::RR: :n .N_......... ............ .. ,
<br /> C'�``.........................'Yes o 'Yes o r `Yes �" o
<br /> , r���� «�...a_ _ ,�:::.::.
<br /> amaofPrinci aI
<br /> �: mnmm�m�m �����. , ..... ..... ..���� m ���������:��,�� ��:n����..................... .......� s SS DOB
<br /> p Residential Addre ,�m
<br /> .
<br /> � , ,�������,R i............... ,,,�m� R,R.�.a_.__m,�,�...... �. � ......_...... ��������� � �
<br /> Title and or Posit.....................................ion Percent �e of C wnersh' Director/LLC Manager US+Citiz '
<br /> MA Resident
<br /> Yes �,'"`` o Yes Jo
<br /> .......__._..r� «,,,,
<br /> . nMIAL HIT3RY.
<br /> Has any individual identified above ever been convicted of a Mate,Federal or Military Crime. C Yes C No
<br /> If yes,attach an affidavit it providing the details of any and all convictions.
<br />
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