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� ��9/1�/2008 02:05 952-401-1629 BALTIC MRTG PAGE 02 <br /> u611�:!:00�1 �L�H�) 1;;: 29 i�A3t 61261.7:601 13C� Hoard �010/016 <br /> r • • . .. . .. <br /> OISCLOSURE OF COMPANY OWNERS, PARTNER.�, OFFICERS <br /> NAME OF SAION:__,�.I�l��{ _ r/F�'S/�/OMf ._..__._..._..._ ...._ <br /> nn applirsns for a 5abn license must Include the fo�lowing inforrt►ation: <br /> . Indlvldual Proprlecor; Provlde the name and address of the Owner <br /> . pennersMlp� Provide tt•e name and address of all General Partners and llmlted F�rtners <br /> • Corporetioa or I.LC: Provide the name and address of all elocted Office�s,Directors,Gov:mors,Meml,��s, <br /> Shareholdwrs owning 10l6 or more of company stock,and aoy NWna�rs/Employ�:�s <br /> wRh authnrlty to exerclse corrtrd in poli�y or management of the cc mpany <br /> 11 ahv OWnl�o►ycRne��s�lso buslnass en�iry,ypp mw1 r»nplek khis fartn to disdose eht awne�s/portnets/oNlee�ilueehaleers�f ehae busMcss enlny as well. <br /> Last f�2rne First Name Middle Initial �^ <br /> �R�s��s �u�,i� �, <br /> Resld�ntiel Address Primary Telephone Nufrtber <br /> a i 9� .� /7��� c oti��- 8� �� 9�a= �r��r-��a� <br /> City State Zip Cpcle • <br /> �X C EL 5 i0 /c' /�i'� 5s" 33/ <br /> TiUe(sycrk une) � T <br /> ✓ 30076 Owner General Partner umited Partner <br /> _„Ele��te0 OfJlc�(title:�„�__� Dlrector _��L�GovernoNMember <br /> Sh,�reholde�(na�centage af pwne►shlp:__96) Me��ger/Employec with tooKolling a�thority ____�__�_�` <br /> Last Nar��e First Name �� Middle In.ti�I���T <br /> Re�id<�n�ial/kidress � Primary Telephone Number <br /> CI[y W� � � State Zip Lode � <br /> Title(�l�e�:one�..._..-- —...�..•--- ---- • <br /> ...__1(�OS6 Uwner � Gener�l Partnsr �imited Partner, <br /> �'I•+�iRci ONlrer(title:___ ___,.) Dlrecror LI,C Cpv�mqr/Membrr <br /> ____Shareholder(Percentag4 of�wnership•__,�,96) Manager/Employee with controlliry;autho�ity ' <br /> Last N:�me T �� —,-••-�-___._ Fi�Name Middle Initial � <br /> _—�.._...�—.�, <br /> RP;idem�a�Address Primary Telephone Number <br /> City—-------• w.M�__ — Sta[e Zlp Code . —._. <br /> ---�•-,-,.. -- --- <br /> T�tlQlrh-c,1�ne1 _...:,«......_...._.�..r—_._..-• —•------.....__..... ...�. <br /> 10�9�Uwnci Generel Partne� I,im�[ed Partner <br /> � :'I«�.�n�1 Uff'��er(title;__,_,,,,�____ ) Oirecto� ll.0 Governnr/Memb�•r <br /> yh.�rF:holder(Perconta of Ownershlp:__%) MSnagcr/Em lo oe with�onhollin auMorlt <br /> ---•----.. ._�._— � P Y 3 Y---- <br /> This form may be photocopied if additional forms are neec ed. � <br />