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1 yn—o Are a regtstere ...... = Yes No _ -3- Personal Information _ If Yes, where are you registered? !S. Address(es) at w ich you ave live during preceding ten years. (Begin,with present i 6• Have you, your spouse, or a parent. brother, sister or chid o either o you, or last address and work back.) ! ever been convicted of any feloJ�y. crime or violation of any ordinance, other than traffic. Yes No // IE Yes, give information as to the time. No, and Street City and State Dates j place, and offense Toe which convictions were had. /11 312 6 I 17. Have you, your spouse, or a parent, brother, sister or child of either of you, ever been engaged as an employee or in operating a saloon, hotel, res urant. cafe, tavern or other business of a similar nature? Yes No If Yes, give information as to the time, place, and lengtFi of time_ la. Kind, name and location of every business or occupation you have been engaged in during the preceding ten years. (Begin with present or last address and work back,) Location: Street Address Nature of Business or 18. Have you been in military service? Yes L,7 No Business or Occupation City and State Occupation If Yes, was discharge(s) ever other than honorable? Yes No 5e ow;-M. MN 55111& (Upon request. you may be required to exhibit all discharges.) I i 1 — being first duly sworn upon his/her oath, deposes and says that he/she is the person w o has executed the above Personal information Form, and that the statements made therein are true of his/her own not..lcJ�gcAaand belief. Signed: 5. \ar..cs :u1J addresses of year employers and partners, it" any, for the preceding ten Subscribed and sw to before his day of 19 . years. (Begin with present or last one first and work back.) Notary rub lic Count), Names: Employers or partners Addresses: Citv and State Dates or !Sy Commission E /Tres 7 JV 19 iii J�FIN C.rK IN 1.11nn. F / Mdsry Pubo,g4on!^E"gVe'uty 29.1986 I r 5 i