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<br />Required 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 />Street Address: <br /> <br />~fll]erH () ff~/f)J{(~./c <br />(~J/5E:Guy) yq.2Z19- Ih/L <br />7cJ9~ POrN! rtVe S' <br />Ce/?rUv'tLLC mf'l C;so38 <br /> <br />Name: <br /> <br />Business: <br /> <br />City, State, Zip: <br /> <br />Applying for: <br /> <br />Q4 Liquor <br /> <br />[ ] Tobacco <br /> <br /> <br />. fir< I e:- <br /> <br />~ <br />