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<br />OPERATOR'S NAME <br /> <br />ADDRESS <br /> <br />PHONE <br /> <br />LIST TWO (2) CHARACTER REFERENCES <br /> <br />NAME <br /> <br />ADDRESS <br /> <br />PHONE <br /> <br />HAS APPLICANT/OWNER HIS/HER DESIGNEE EVER BEEN CONVICTED OF A CRIME, <br />OTHER THAN A TRAFFIC VIOLATION: <br /> <br />o YES 0 NO <br /> <br />IF YES, GIVE EXPLANATION ON A SEPARATE SHEET OF PAPER, INCLUDING TIME, <br />PLACE AND NATURE OF EACH CRIME OR OFFENSE AND DISPOSITION THEREOF, <br /> <br />LIST ALL CREDITORS INVOLVED IN THE CONSTRUCTION AND MAINTENANCE IN ANY <br />WAY PROVIDING DEBT OF EQUITY FINANCING TO SAID OPERATION: <br /> <br />LIST CORPORATE OR PARTNERSHIP TITLE, IF ANY <br /> <br />CORPORATE OR PARTNERSHIP ADDRESS: <br /> <br />LIST ALL OFFICERS, MANAGERS OR DIRECTORS, IF CORPORATION: <br /> <br />NAMES <br /> <br />ADDRESS <br /> <br />DATE OF BIRTH <br /> <br />Please submit accurate and complete business records showing names and addresses of all individuals <br /> <br />Page 11 of 12 <br />