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CITY OF ORONO <br />IN. SUPPORT OF AN <br />APPLICATION FOR ON -SALE INTOXICATING LIQUOR LICENSE <br />AND OFF -SALE INTOXICATING LIQUOR LICENSE <br />PART 11 - Personal Tnfnrmatinn <br />Directions: This form must be filled out in duplicate with tvpewriter or <br />by printing in ink by the sole owner, by each partner, by each <br />officer, or director, by each manager, proprietor or other per- <br />son with management responsibilities for the premises, by each <br />person who by combined ownership or control has an interest inin <br />a corporation or association in excess of 5%. <br />Date <br />sVty p�t��S - <br />'RUE NAME:(first) (filll middle) (maiden name) ! ast) <br />�.ESIDZNCE ADDRESS: (Street, C tv, Sta, ) PHONE NUMBER) <br />\\� p`kcrt. �. � (3Lyoc1 _ <br />3USINESS NAME: <br />c 1k, ��',�e. �j Ay��t t► ��:„ �� 1— ��Sc► L► <br />IUSINESS ADDRESS: (Street, C , State) (PHO?IE "DUMBER) <br />r \S �,��� `�V4, I l 4�_ <br />)LACE OF RTH: (City, 0ounty, State) DATE F 8 TH:(mo.,dav,y- <br />r t o �' O ro N �aiW <br />iEIGHT : WEIGHT: COLOR OF HAIR: CILOR OF EYES: <br />:.S. CITIZEN? Yes_ NaturaliZed? Yes_ — "_ yes, give date and place: <br />No No�� <br />4ARITAL STATUS: Married Single Divorced <br />if married, true name, place and date of birth, and residence address of <br />spouse: <br />w�ov U �wlaSov Q'C 1 <br />:RUE NAME: (first) u mi e, ma den name(last) <br />OF BIRT 4. ty, C. <br />Wl_ <br />,S N E AD— D S: t5treet, City, t to �- <br />.f you have ever used or been known by a name or names other than the tzoe name <br />liven above, list �such name(s) and information concerning dates and places used. <br />