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5. Please provide the following information of the manager, proprietor, or other agent in charge of the individual's, corporation's or association's preinises to be licensed: Name: 1��Cti'ir1.Gl,l!l..�i�' '��Ir'CI r� � G�1 ��C��:� Last F3.v�t Middle Date of Birth: � � � � � / � � � � Personal Address: I�j I� 1� t/ �( Gi-q � CI�' �j . r�11,1 �}'L�'� L1 � ��, 1�(1 i`I ��j,��% -� Str'eet City � State ZIP Personal Telephone: ��°� �r �-�(�� (%!.�'� 6. If applicant is an individual (If not, skip to next section): Name: Last First Middle Date of Birth: Personal Address: Street City State ZIP Personal Telephone: Business Address: Street City State ZIP Business Telephone: 7. If applicant is a partnership, list information fo� each member with an interest in the partnership and indicate who will be the managing partner (If not, skip to next section): The managing partner will be: A. Name: Last First Middle Date of Birth: Interest % Personal Address: Street City State ZIP Personal Telephone: Business Address: Street City State ZIP Business Telephone: Page 2 of 10