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CITY OF ROSEVILLE <br />FINANCE DEPARTMENT, LICENSE DIVISION <br />APPLICATION FOR <br />PAWN SHOP AND PRECIOUS METALS DEALER <br />Part II - Personal Information <br />Directions: This portion of the application should be completed for the sole owner, each general and <br />managing partner, each officer or director, each manager, proprietor, or any other individual or <br />agent in charge of the licensed premises and by each person who by combined ownership or control <br />has interest in excess of five (5) percent. <br />Date: i��e �% � �� '�(� � � <br />1. Full Name: <br />� <br />Last First � Middle <br />2. Personal Address: I��E��� �L'1Gt..c��-I �2D���'"��Ti�- lU�� �Y�D+�' �-��t-�'-L� r`�'1J�-1 ����y�- <br />Street City State ZIP <br />3. Personal Telephone: ����- �y� � I� �� <br />4. Susiness Address: ��I �j�l�V'�Ie�G(G c1� �, l�jLl.�nS�✓11 ���, M/��' ���� <br />Street <br />5. Business Telephone: ��i �1--F�Q - �%� <br />State ZIP <br />6. Place of Birth: ��" ��--lJ L l �`'� � i'� ��,� I a�l LI %� <br />County City ' State <br />7. Date of Birth: ��% �'I % I°�'I(.�'� <br />MM/DD/YYYY <br />8. US Citizen? Yes %� No <br />Naturalized? Yes No X-- If yes, give date and place and attach a copy of the <br />naturalization papers: <br />9. If yau have ever used or been known by a name or names other than the true name given in <br />No. 1 above, list such narne(s) and inforrnation concerning dates and places where used: <br />!:� 1'��t. c.� L,��"d t V1�-►�� �ll,c ►'� � Gt- i� � LI l,(,� S`�' ��Y^G�C_� (�'�-I <br />Page 7 of 10 <br />