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11. FATHER'S NAME: 04/( acaN1� 12. MOTHER'S MAIDEN NAME: 4 r D j <br /> 13. IDENTIFY YOUR CRIMINAL RECORD, (Massachusetts, Military, any other State or Federal):ANY OTHER <br /> ARREST OR APFE.AFA.NCE IN CRIMINAL COURT CHARGED WITH A CRIMINAL OF-4NSE <br /> REGARDLESS OF FINAL DISPOSITION: <br /> YES X NO (��SLCI�EC7C EiTH RYES OR NO) <br /> IF YES, PLEASE DESCRIBE OFFENSE (S) SPECIFIC CHARGE AND DISPOSi T ICN (FINE, <br /> PENALTY, ETC.) <br /> 14. PRIOR EXPERIENCE IN THE LIQUOR INDUSTRY: — L YES NO <br /> IF YES, PLEASE DESCRIBE: <br /> Aga <br /> 15. FINANCIAL INTEREST, DIRECTOR INDIRECT, IN THIS OR ANY OTHER LIQUOR LICENSE, PERMIT <br /> OR CERTIFICATE: aC YES NO <br /> IF YES, PLEASE DESCRIBE: //1 C! Aal nK Aq <br /> 16. EMPLOYMENT FOR THE LAST TEN YEARS (Dates, Position, Employer, Address and if known, ' <br /> Telephone Numbers): <br /> lee <br /> pp <br /> 17. HOURS PER WEEK TO BE SPENT ON THE LICENSED PREMISES. 'A'Mrs 'Oe/- <br /> 18. I HEREBY SWEAR THAT UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE <br /> INFORMATION I HAVE GIVEN IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE <br /> AND BELIEF. r' <br /> BY: }�1��1`A <br /> PROPOSED MANAGER SIGNATURE DATE <br /> I <br /> F!F1LE3uAALIRE=N.'.mAuREENTORXISs FCRMA..',VPO <br /> 9199 <br /> 2 <br />