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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 premis< <br />control an interest in excess of 5%) <br /> <br />Street Address: <br /> <br />----rloVr\ ~ Q, 9 w 1C,W.s~ N <br />, . <br />K"i.-li '-(s t<OlUJ'Zr:"~ {' tNT-L~LJ1..u...<=i.... ]:IJ t. <br />'tot:! e, C '2: tuT"2 12. Ul U'E. Q..O. <br />~o:z:.m-~I.l~LL<;' ,,-\u. S-;;D5,8. <br /> <br />Name: <br /> <br />Business: <br /> <br />City, State, Zip: <br /> <br />Applying for: <br /> <br />W Liquor <br /> <br />IXI Tobacco <br /> <br /> <br />\AVL'D <br /> <br />-50- <br />