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On Sale and <br />Pe:-sinal Information - Part 11(Off Sale Intoxicating) <br />17. (cont' } <br />Name F Residence Address <br />Business Address 1 a = ti <br />Name <br />Business Address <br />Name v �' <br />Business Address <br />L- <br />u <br />Residence <br />Address <br />Residence Address <br />sPhone ; gloo <br />` b <br />Phoi.i <br />L43 tu, F_. \� <br />415 - 7-9 67 <br />Phone L113 -S 41 q <br />ANY FALSIFICATION OF ANSWERS TO THE ABOVE QUESTIONS WILL <br />RESULT IN DENIAL OF THE APPLICATION. <br />A Financial Statement of net worth and a short autobiography must accompany <br />this application for all persons who are recuried to complete a Part 11 Per- <br />sonal Information form. (Exception - Manager, Assistant Manager, Food Manager, <br />and Beverage Manager, provided these individuals are not partners, o f1'6* rs of <br />an interest in excess of fi�ve_perce <br />corporation or do not hold .) <br />Y <br />(signature of applicant) <br />Subscribed and sworX to before mpI a Notary_ <br />Public on this day of "'_s:1 ��• <br />(Notary Signature) Commission Expires On <br />SNI►AON RO8ENDAlE <br />' y MpTNlfr NI�LIC - IIMMIsipTA <br />NEN!VEPIN COUNTY <br />My Cannirron ENMN ti tt. tNt <br />-5- <br />