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The COmmontiVealrh of lvlassachtcserrs <br /> TheAicohoIicBeverages Control Commission <br /> - 239 Causeway Stree-Suite?00 <br /> Boston,:VLA 02114 <br /> Telephone: 617-727.3040 <br /> �. FAX: 617-727-1258 <br /> FORM A <br /> LICENSEE PERSONAL INFORMATION SHEET <br /> THIS FORM MUST BE COMPLETED FOR EACH: <br /> A. NEW LICENSE APPLICANT <br /> B. APPOINTMENT OR CHANGE OF MANAGER � <br /> IN A CORPORATION <br /> C. TRANSFER OF LICENSE (RETAIL ONLY-SEC. 12 & SEC. 15) <br /> (Please check which transaction is the subject of an application accompanying this Form A.) <br /> PJ�FP,SF TYPE OR PRINT Al I_ NfQ MATION <br /> �LL QUESTIONS MUST BE ANSWERED AND TELEPHONE NUMBERS PROVIDED OR <br /> APPLICATION WILL NOT BE ACCEPTED. <br /> t. LICENSEE NAME !J/f rh C. <br /> (NAME AWIT WILL APPEAR ON THE LICENSE) <br /> 2. NAME OF (PRO POSE'C) MANAGER A10 A a mmae4 i (! <br /> 3. SOCIAL SECURITY NUMBER Y60 - 7S- 7o2 <br /> 4. HOME (STREET) ADDRESS 9,2 <br /> 5. AREA CODE AND T E, EPHONE NUMBER (S): (Give both,your horse teieohone and a number at which <br /> you can be reached during the day). <br /> DAYTIME "" HOMES f SOS y2 O - g77 `1 <br /> 6. PLACE OF BIRTH: &kT-s ►'L 7. DATE OF BIRTH: _1116 <br /> 8. REGISTERED VOTER: SC - YES NO SA. WHERE ?: rn u b e <br /> 9. ARE YOU Alf. S. CITIZEN: _K YES NO <br /> f, C't 8� {� Z 6 <br /> U. :�U rt l AND UhT vie i r- _ LjF� -:7 <br /> C iv'iv �I ;ice=�it.rlcL=;: h 9 1 <br /> (Submit proof or citizenship and/or naturaiizatien such as Voter's Certificate, Birh Certificate or <br /> Naturalization Papers) <br /> (Over) <br /> C, <br /> 1 . � <br />