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<br />Required Information for Background Checks <br /> <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: <br /> <br />f),lIJ.. ./lIE) /V ~!/t/ <br />Business: fJl~~ ~~~ 1J~6j- <br />S__, ~~ /Cf <br />City, State, Zip: _ cS-So3y <br /> <br />T~~ <br /> <br />Applying for: <br /> <br />~ Liquor <br /> <br />P'i Tobacco <br /> <br />