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C�TY OF ROSEVILLE, �+IINN1350TA <br />APPLICATION F�R PAWN SHOP/PRECIOUS 1�ETAL �EALER <br />Part II - Personai Informata�on <br />Direc ians: <br />Please complete, in duplicate, with typewriter or by printi.ng in <br />ink. � <br />This portion of the application should be completed for the sole <br />owner,each genera2 and managing partner, each of�icer or director, <br />each manager, proprietar, or any other individual or agent in <br />charge of the licensed premises and by each person who by combined <br />ownership or contral has an interest, in excess of 5� <br />Date : I2' �' �� <br />f. . <br />1. True Name n 1 J� l T �i,.�i 11 i p��� � <br />I.AST FIRST <br />�. Residence Addr�ss� <br />3. xe5iuence •1•eiepnone • <br />�� Rv�ine�� a,ddress <br />5. �sus�ness �!'elephone. <br />1�IIDDLE NAME <br />6. Place of Birth _ _ , <br />COUNTY CITY STATS <br />7. Date Of Birth _ <br />l�O./DAY/YEAR <br />S. U.S. Citi.zen? Yes_� No <br />Natura�ized? Yes No If yes, give date and place <br />(Attach a copy of the aaturalization papers) � <br />9. If you have ever used or been known by a-name or names other <br />than the true name given in No. 1 above, list such name(s}, <br />and information concerning dates and places where used: <br />ames Dates, Place. and Circums�ances <br />rr. r-� .... 1 1 C'�� i �►.�P lr/" �.. r�. �nn r� l�.� .. �. 1 i.L.�r► <br />