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I Wicate below changes ofeo o to ce ,_ +� home add[CM or telephone numbers <br /> ludi below any interest whatsoever, directly or indirmtly in liquor • <br /> pr <br /> hilth MOLIest 4-ada.,no Lie, tluaLu 471,7 �Sutks Own4va)n tKol 5 �6�el L6ame, <br /> 7)r)n, )e f <br /> Rewrt below details of l' law violations (civil or criminal) that have occurred within the last five years. (Dates, offenses, <br /> fines or other penalties. including L apor Control p�na : <br /> Report below details involving anv license reiections or revocations: <br /> City/County Comments: <br />