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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 />Business: <br /> <br />""Ul~~ ;L..,,- <br /> <br />~-- &,(.~S <br /> <br />Name: <br /> <br />Street Address: <br /> <br />\~~D M~.'&) ~r <br />~""~ \... f'\II..J S Sb3@. <br />I <br /> <br />City, State, Zip: <br /> <br />Applying for: <br /> <br />[ ] Liquor <br /> <br />Dd'Tobacco <br /> <br />I 11,1 '\,llllc' \l,lIdk '\,lllle l ,)"[ ;'\<1111<:' 1).11 L' () I \ddIL"';, <br />1)11111 <br />~ Ml~A:H" ~~~ &1 'l,l~ '6 1f11l. '1Z~4o> l)fI.. C~~ I~\ M.....:> 5' <br />1000 <br /> <br />'563& <br />