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<br />------,. <br />-.---.. <br /> <br />CITY "OF CENTERVlLtE . <br />INTOXICATION MALT LIQUOR LICENSE <br />APPLICATION <br />DRAM SHOP INSURANCE EXEMPTION <br /> <br />I hereby certify under penalty of perjury that I have applied for an intoxicating liquor/on- <br />sale wine license ana..that tt", "afc:s vf :su",h B8""a8~il aR lililil tbm t 1 O,QB9 per )c:ftf. In <br />addition. I certifY that the attached list of mv wholesale suppliers is true and correct. If <br />necessary, these suppliers may be contacted in order to confirm this declaration. <br /> <br /> <br />//J." ;22- <br /> <br />" <br /> <br />{)7 <br /> <br />Date <br /> <br /> <br />/tI / z. V;/07 <br />Date <br /> <br /> <br />. <br /> <br />JMEI PATRICK 8fWIa41 <br />NO'TNIYPIIar ._m <br />1Ite.-......_ ...... <br />F <br /> <br />NOTE: A LIST OF YOUR WHOLESALE SUPPLIERS MUST ACCOMPANY THIS <br />DRAM SHOP EXEMPTION FORM. <br /> <br />~Jr~ <br />(i1~ ~ ~ <br />)/~ <br />;11M JLLC <br />-~~ <br /> <br />--~-:T~ ~. <br />124. <br />--IJ~ <br />