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<br />r <br /> <br />Business: <br /> <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 premises and for all person who own or <br />control an interest in excess of 5%) <br /> <br />~t/l, H!J/V7A;;1/ <br />flfcn~~ ~F~ ~ 06;9- 7h ~ <br />?O'b~, ~~)p ~ <br />~~,d.4 ,mIJS50-Y/) <br />/ $ <br />r Liquor <br /> <br />~ Tobacco <br /> <br />Name: <br /> <br />Street Address: <br /> <br />City, State, Zip: <br /> <br />Applying for: <br /> <br /> <br />~ t&:~ ,t'!tU S>D 71 <br /> <br />~. <br />