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<br />.- I <br /> <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 />Street Address: <br /> <br />\JJ;'a~1":;) ~i~U71 <br />~~,.. ~~~ <br />10'\'5 'W~~. ~. <br />~\lk...mN. to?~~ <br /> <br />Name: <br /> <br />Business: <br /> <br />City, State, Zip; <br /> <br />Applying for: <br /> <br />ts<f Liquor <br /> <br />[ ] Tobacco <br /> <br /> <br />.-.--, <br />\ ol)9 <br /> <br />tJ\~ <br /> <br />~\.lj <br />S-r-~~ <br /> <br />(,"I"\\, CA~ ~ <br />~V1;Ll. M...l ':;<;01& <br />