Laserfiche WebLink
Page 9 PLEASE TYPE OR PRINT ALL INFORMATION <br /> STATE ASSIGNED LICENSE NUMBER 0252 _ 44 005 003 <br /> ALL APPLICANTS ANSWER THE FOLLOWING <br /> 9.1 DOES ANY INDIVIDUAL,PARTNERSHIP,CORPORATION OR ASSOCIATION OTHER THAN THE APPLICANT HAVE <br /> AN INTEREST DIRECTLY OR INDIRECTLY IN THE LICENSE APPLIED FOR OR IS THE STOCK OF ANY <br /> STOCKHOLDER HELD IN ESCROW OR PLEDGED IN ANY WAY? Yes XX No <br /> IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION OF INTEREST. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. <br /> Name of Individual(Last Name First)or Corporation <br /> (Last Name, First Name,Middle Initial or Corporate Name) <br /> Social Security Number - - OR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of interest <br /> 9.2 DOES ANY INDIVIDUAL,PARTNERSHIP,CORPORATION OR ASSOCIATION HOLD ANY CHATTEL MORTGAGE OR <br /> CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOODS OR <br /> EQUIPMENT TO BE USED IN CONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSE <br /> APPLIED FOR? Yes XX No <br /> IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. <br /> Name of Individual(Last Name First)or Corporation <br /> (Last Name, First Name,Middle Initial or Corporate Name) <br /> Social Security Number OR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of Interest <br /> 9.3 HAS THE APPLICANT AGREED TO PERMIT ANYONE NOT HAVING AN OWNERSHIP INTEREST IN THE LICENSE TO <br /> RECEIVE OR AGREED TO PAY ANYONE(BY WAY OF RENT,SALARY OR OTHERWISE)ALL OR ANY PERCENTAGE <br /> OF THE GROSS RECEIPTS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTED <br /> UNDER THE LICENSE APPLIED FOR? Yes Sri No <br /> IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR <br /> CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. <br /> Name of Individual(Last Name First)or Corporation <br /> Last Name First Name Middle Initial <br /> Social Security Number - - OR <br /> NJ Sales Tax Certificate of Authority Number <br /> Street Address <br /> Number Street Name <br /> P.O. Box# Municipality State <br /> Zip - <br /> Describe Nature of Interest <br /> APPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 13A. CORPORATIONS AND LIMITED LIABILITY <br /> COMPANIES COMPLETE PAGE 10. <br />