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<br /> ............ uw..... I \JU......... V. ....... <br /> . J...li....l\.....I'...... ~ n.:!.... UJ...1\.U.'.... <br /> -.)L....,~ Ut.~ J...li....l\JV.' t ~\...1...r. U~\U...:'L..:-:.....,; ~-;'-'~: ~""'l"":;....;...;\.:t I'lS . 612 633-7839 P.03 <br /> I <br /> I Cily of Ardcn Hills On Sale Liquor License Appliclltion Page 2 <br /> ~ List aU partners/officers/director, if corporation: <br /> Name and Title: Address: Date of Birth: <br /> Nghi Sam 454 Carlisle Lane, Rochester, HN S5901 2/27/50 <br /> Vay Sam 454 Carlisle Lane, Rochester, MN 55901 ~ 8/44 <br /> I <br /> I Is applicant a ciliLen of the United States: Ycs_" x No <br /> If naturalized, staled sale and place of naturalization: La Crosse, Wiscon~in <br /> I If u corporationlpannershlp slllte eiti:t>>n>hip .tatus for all ofticers or partners; <br /> I Vav Sam, Citizen <br /> Nghi Sam, Citizen <br /> I Slalc full name and addre~s Qf ~pOuSe for person execul\n,g lhis applicadnn: <br /> Vay Sam, 454 CarliS1G Lane, Rochester, MN 55901 <br /> I State occupations ofapplication and associates for the past five )/earll: opera.ted Great China <br /> Restaurant in Rochester, Minnesota. for nine yeal:'S. <br /> Ie )fCorporation, complete the follo\\'ing: <br /> Date ()f incorporalion:_." pending State of Incorporation: Minnesota <br /> I Amount of paid capi tal H70,OOO_OO <br /> In <br /> I Stale if subsidiary of any other corporation: Minne.sota <br /> I Stale purpose of corporation: Minnesota <br /> I liS! Names and Addresses of all officers/directors and stnckholdel's and the number of shlln\S held <br /> by each: Name Address Number of Shares <br /> I Nghi Srun 454 Carlisle Lane, Rochester, MN 55901 50 <br /> Vay Sam 454 Carlisle Lane, Rochester, MN 55901 50 <br /> I <br /> I <br /> it <br /> I <br />