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Part 1 - General Information (Off Sale JIrtoxicating) <br />22. Names, resicir:nce addresses, business addresses, and telephone numbers <br />of three persons, residents of Hernepii,. County, of good moral charac- <br />ter, not related to the applicant or financially interested in the <br />premises or business, who may be referred to as the applicants charac- <br />ter. f <br />Full Name � � 1 _ Phone _`z- <br />(area code No <br />Residence Address bb C <br />street itv State c� zip <br />Business Address o r ���� \� �� , Dhone d -So-%�I *c <br />street City (State) (Arca—fie N <br />Full Nanec ��o�Gb'L �pt NP Phone �z l-U8s <br />(area code G No <br />Residence Address Lv-ez N, . <br />street) (City (State) ((zip) <br />VBusiness Address �. Phone,_ _ <br />(street (City) State (rrea cede N <br />Full hane�� �► ` _Phone <br />(area code I. No <br />Residence Address <br />(street) (City) (State) (74) <br />hone <br />Business Address <br />(street) (City) (State (area co 6 <br />ANY FALSIFICATION OF ANSWERS TO THE ABOVE MESTIONS WILL RESULT IN <br />DE � 0 THE APPLICATION. <br />A Financial Statement of net worth and a short autobiography accompany <br />this application for all persons who are required to complete a :Irt 11 Per <br />sonal Information form. (Exception - Manaoer and Assistant Manar-r provide <br />these individuals are not partners or officers of corporation. <br />x <br />(sinature o app <br />cscant <br />Subscribed and sworn to be$pre me a Notary <br />Public on this_-_,,' day of �. '1 19 <br />(%otar•: s. -nature ; Commission Exi ires On <br />-�� SHARON ROSENDAIE <br />IL4 M0/MY PUGLIC "WWf30TA <br />HEN%EPtN COUNTY <br />My .,al..awNM1� t.D, NI 9.W Y� <br />