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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 <br />1 Lr\ LP;V <br />*Attach Additional List of Necessary <br /># of Shares Owned Date of Birth <br />/rip <br />(10) The name and address of each director of the applicant is as follows: <br />(11) The name and address of each officer of the applicant and the office held by each is <br />as follows: <br />Name <br />Address <br />Title <br />Date of Birth <br />UV +LS 'V J <br />1 <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 />Name (Print) I Title (Pr <br />Signature:6t26' /'� n <br />To Be Completed By Office: <br />Date <br />Date Request Rpceived <br />By Q, e $2,000.00 On -Sale Fee Received <br />Staff Member) $200.00 Sunday On -Sale Fee Received <br />Look for us on the World Wide Web at gemlakenin.org <br />9Yes / ❑ No <br />_Yes / ❑ No <br />