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<br />NAMES <br /> <br />ADDRESS <br /> <br />DATE OF BIRTH <br /> <br />Please submit accurate and complete business records showing names and addresses of <br />all individuals having an interest in business including partners, officers, owners and <br />creditors furnishing credit for establishment acquisition and maintenance and furnishing <br />of said business. <br /> <br />Please furnish accurate documentation establishing the interest of the applicant and any <br />other person having interest in the premises upon which the building is proposed to be <br />located or furnished thereof. The documentation shall be in the form of a lease, deed, <br />contract for deed, mortgage deed, etc. and any other documents establishing interest of <br />the applicant or any other person in the operation. <br /> <br />Please provide blueprints, diagrams, layouts, etc. showing construction and or remodeling <br />to the premises and specifically showing the layout of the bathing and restroom facilities <br />to be used. <br /> <br />Applicants and his/her associates will strictly comply with all regulations promulgated by <br />the City Council of City of Centerville and all ordinances of said municipality. <br /> <br />I hereby certify that I have read the foregoing questions and that the answers to said <br />questions are true of my own knowledge. I further understand that an investigation fee, <br />not to exceed $250.00 shall be charged an applicant by the City. <br /> <br />Signature of Applicant <br /> <br />Subscribed and sworn to before me <br />This day of , 2002 <br /> <br />Notary Public Signature <br /> <br />My Commission Expires <br /> <br />Page 12 of 12 <br />