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iislivi util <br />Full name <br />Horne address: <br />Phone Number <br />Business Address <br />Phone Number <br />Date of Birth <br />m j <br />ENDIVIDUAL <br />(Ta be cwmplefe<i by an Individual Owner) <br />Fust Mid(lle <br />Last <br />Manager, proprietor or other agent urs charge of the individual owner's premises to be licensed <br />Full name Fast M ddle Last <br />Date of Birth — <br />Home Address: <br />Phone Number �o �c Wolk <br />PARTNERSHIP <br />(To be complefed by a Parlue:) See AWao-11etr' <br />List each membri of the partnership and the member's interest <br />Full 31ame First Middle Last <br />Home Address: <br />Phone Number Work <br />...___... ......... <br />tyIamLe s Intel <br />Date of 13 it ih <br />F'uIl name <br />Homo Address: <br />Phor to Number <br />Member's Interest <br />Date of Birth <br />Full mulle <br />Horne Address: <br />Phone Number <br />Member's Interest <br />Date of Birlh <br />Full narue <br />Home Address: <br />Phone Number <br />Member's Interest <br />Date of Binh <br />First NUdle <br />Fust Middle <br />First <br />The managing partner will be <br />Full Name <br />Middle <br />Work <br />Last <br />Last <br />Last <br />The manager, proprietor or th�gent in charge of the partnership's premises to be licensed: <br />Full name asst h Middle T- LastI�p� <br />Home address ------A..6-U <br />Phone Number home ak&Ag �� �� ork <br />Data of Birth Inn -,�9. IQI-2 <br />