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Page 10 PLEASE TYPE OR PRINT ALL INFORMATION 0252 44 005 003 STATE ASSIGNED LICENSE NUMBER _ QUESTIONS TO BE ANSWERED BY CORPORATIONS AND LIMITED LIABILITY COMPANIES ONLY. ANY CORPORATION OR LIMITED LIABILITY COMPANY THAT IS REPC)RTED TO HAVE AN INTEREST IN THE BUSINESS TO BE LICENSED,WHETHER THE LICENSEE COMPANY, THE PARENT CORPORATION OF THE LICENSED COMPANY, HOLDING COMPANY OR OTHERWISE AFFILIATED IN THE CORPORATE CHAIN, MUST ANSWER THE FOLLOWING USING A SEPARATE PAGE 10 AND PAGE WA FOR EACH CORPORATION. ANSWER QUESTIONS ON BOTH PAGE 10 AND PAGE 10A FOR EACH CORPORATION, 10.1 Name of corporation E.G. holding Corporation Inc. 10.2 Street address of home office_ 370 Chestnut Street Number Street Name Municipality Union _ NJ 07083 State Zip - 10.3 NJ Sales Tax Certificate of Authority Number 221-358-650/001 10.4 IF CORPORATION ADDRESS IN NUMBER 10.2 ABOVE IS OUT OF STATE,REPORT BELOW THE ADDRESS OF ANY OFFICE LOCATION IN NEW JERSEY. INSERT N/A IF NONE. Street Address N/A Number Street Name Municipality New Jersey Zip - 10.5 IS THE CORPORATION NOW AN EXISTING,VALID CORPORATION? XX Yes No 10.6 DATE CHARTERED OR INCORPORATED Jan / 17 / 1995 STATE NJ 10.7 CERTIFICATE OF INCORPORATION NUMBER 0100612883 10.8 IF NOT INCORPORATED UNDER THE LAWS OF NEW JERSEY, HAS THE CORPORATION RECEIVED AN AUTHORIZATION TO CONDUCT BUSII,IESS IN NEW JERSEY FROM THE NEW JERSEY OFFICE OF THE SECRETARY OF STATE? __Yes X 1( No 04,\la }.r4.1151,0 10.9 HAS THE CORPORATION CHARTER EVER BEEN REVOKED BY THE OFFICE OF THE SECRETARY OF STATE IN NEW JERSEY? Yes . XX No IF THE ANSWER IS"YES,"INSERT THE DATE OF REVOCATION,OR IF SUSPENDED,THE BEGINNING AND ENDING DATE OF THE SUSPENSION. Date of revocation / / Beginning date / / Ending date /. / 10.10 INSERT THE NAME AND ADDRESS OF THE REGISTERED OR AUTHORIZED AGENT IN NEW JERSEY UPON WHOM SERVICE OF PROCESS IN ANY PROCEEDINGS AGAINST THE APPLICANT, PURSUANT TO THE NEW JERSEY ALCOHOLIC BEVERAGE LAW,THE ALCOHOLIC BEVERAGE TAX LAW OR PROCEEDINGS IN A STATE OR U.S. DISTRICT COURT, MAY BE MADE. Name E.G. Holding C'b p. Inc. c/o Stephen Heh1, Esq. (Last Name, First Name,Middle Initial or Corporation) Street Address 370 Chestnut Street, P.O. Box 807 Number Street Name Municipality. Union New Jersey zip 07083 _ Telephone Number ( 908 ) 687 - 7000 Area Exchange Number 10.11 IF THE LICENSED COMPANY IS OWNED BY OTHER CORPORATION(S)OR IS IN A CORPORATE CHAIN,ATTACH A DIAGRAM DEPICTING THE CORPORATE RELATIONSHIPS AND THE PERCENTAGE OF STOCK INTEREST IN THE COMPANY TO BE LICENSED, OWNED BY OTHER CORPORATIONS OR OTHER NON-CORPORATE ENTITITES (INDIVIDUALS, PARTNERSHIPS,ASSOCIATIONS).