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not be effective until a permit shall be issued under the laws of the United States in <br />case such permit is required under said laws; and that the applicant will keep said <br />license posted in a conspicuous place in said premises; and, <br />(9) The name and address of each shareholder of the applicant and the number of <br />shares owned by each is as follows; <br />me Address ; # of Shares Owned Date pf Bi <br />*Attach Additional List of Necessary <br />(10) The name and address of each director of the applicant is as follows: <br />Blame - Address Date of Birth <br />(11) The name and address of each officer of the applicant and the office held by each is <br />as follows: <br />Name - Address - - Title Date of Birth <br />(12) The undersigned certifies that all information provided in this application is true and <br />accurate and that he/she is properly credentialed to make this application. <br />i o be uomoietea by uttice: <br />Date Request Received <br />By <br />(Staff Member) <br />$2,000.00 On -Sale Fee Received ❑ Yes / ❑ No <br />$200.00 Sunday On -Sale Fee Received ❑ Yes / ❑ No <br />Look for us on the World Wide Web at gemlakenm.org <br />