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DISCLOSURE OF COMPANY OWNERS, PARTNERS, OFFICERS <br /> R / � <br /> NAME OF SALON: C� GL �-G-L .lJ� <br /> An applicant for a Salon license must include the following information: <br /> . Individual Proprietor: Provide the name and address of the Owner <br /> • Partnership: Provide the name and address of all General Partners and Limited Partners <br /> • Corporation or ILC: Provide the name and address of ali elected Officers,Directors,Governors,Members, <br /> Shareholders owning 10%or more of company stock,and any Managers/Employees <br /> with authority to exercise control in policy or management of the company <br /> If any owner or partner is also business entity,you must complete this form to disclose the owners/partners/offlcers/shareholden of that business eMity as well. <br /> Last Name Firstt Name Middle Init'al <br /> �/�' �� L_�-li(itN! v� �� <br /> Residential Address Primary Telephone Number <br /> �� ` Cs o� <br /> �� State . � <br /> � � <br /> Title check one) <br /> 100%Owner General Partner Limited Partner <br /> Elected Officer(title: ) Director LLC Governor/Member <br /> Shareholder(Percentage of Ownership: %) Manager/Employee with controlling authority <br /> Last Name First Name Middle Initial <br /> Residential Address Primary Telephone Number <br /> ��tY State Zip Code <br /> Title(check one) <br /> 100%Owner General Partner Limited Partner <br /> Elected Officer(title: ) Director LLC Govemor/Member <br /> Shareholder(Percentage of Ownership: %) Manager/Employee with controlling authority <br /> Last Name First Name Middle Initial <br /> Residential Address Primary Telephone Number <br /> City State Zip Code <br /> Title(check one) <br /> 100%Owner General Partner Limited Partner <br /> Elected Officer�title: ) Diredor LLC Governor/Member <br /> Shareholder(Percentage of Ownership: 96) Manager/Employee with controlling authority <br /> This form may be photocopied if additional forms are needed. <br /> 5 <br />