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Page 9 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 0722 44 - 046 008 ALL APPLICANTS ANSWER THE FOLLOWING 9.1 DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION OTHER THAN THE APPLICANT HAVE AN INTEREST DIRECTLY OR INDIRECTLY IN THE LICENSE APPLIED FOR OR IS THE STOCK OF ANY STOCKHOLDER HELD IN ESCROW OR PLEDGED IN ANYWAY? Yes XX No IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION OF INTEREST. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. Name of Individual(Last Name First)or Corporation (Last Name, First Name,Middle Initial or Corporate Name) Social Security Number - DR NJ Sales Tax Certificate of Authority Number Street Address Number Street Name P.O. Box# Municipality State Zip - Describe Nature of Interest 9.2 DOES ANY INDIVIDUAL,PARTNERSHIP,CORPORATION OR ASSOCIATION HOLD ANY CHATTEL MORTGAGE OR CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOODS OR EQUIPMENT TO BE USED IFONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSE APPLIED FOR? Yes No IF THE ANSWER IS'YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. Name of Individual(Last Name First)or Corporation (Lest Name,First Name, Middle Initial or Corporate Name) Social Security Number - - OR NJ Sales Tax Certificate of Authority Number Street Address Number Street Name P.O. Box# Municipality State Zip - Describe Nature of Interest 9.3 HAS THE APPLICANT AGREED TO PERMIT ANYONE NOT HAVING AN OWNERSHIP INTEREST IN THE LICENSE TO RECEIVE OR AGREED TO PAY ANYONE(BY WAY OF RENT,SALARY OR OTHERWISE)ALL OR ANY PERCENTAGE OF THE GROSS RECEIPTS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTED UNDER THE LICENSE APPLIED FOR? Yes XX No IF THE ANSWER IS"YES,"ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED, Name of Individual(Last Name First)or Corporation Last Name First Name Middle Initial Social Security Number - - OR NJ Sales Tax Certificate of Authority Number Street Address Number Street Name P.O. Box# Municipality State Zip - Describe Nature of Interest — APPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 10A. CORPORATIONS AND LIMITED LIABILITY COMPANIES COMPLETE PAGE 10.