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<br />Req uired Information for Background Checks <br />(Required for the following: sole owner, each partner, each officer, each agent or manager in charge of the premises and for all person who own or <br />control an interest in excess of 5%) <br /> <br />Name: 5.dH4tJiC' 1; /JJ)JI)jl) f ~,u I ~t, <br />, <br /> <br />Business: . 54bt~ ~ j]~ R..r ;tJ -' /b;?J ,L. <br />Street Address: 71Jr6 (';~f 6/hIJ()., ( IlOM <br />City, State, Zip: (Ifill f,/lIJltt (j /J1/lJ I $5P.3f <br /> <br />Applying for: <br /> <br />~] Liquor <br /> <br />~ Tobacco <br /> <br /> <br />~ <br />