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Individual Pull name Horne address: Phone Number Business Address Phone Number Dateof Bath PART 1 LND-RTIJ)'U L (ro be completed by m Individual Owner) First Middle Last Manager, proprietor or other agent in charge of the ivdi.vidual owner's premises to be licensed. Full name Middle Lasf Firs" Date o Birth -------.___--- --- —.— Home Address: --- . Phone Number I'.omc Work-- eA.RT [IISS IP (To be completed by a Psul-ff) List each member of the paruicrship and the m,ernber's interest Full name st M dd e ast Home Address: _ _ Phone .Nilmber hone .. weak mainber's Interest Date of Birth Full name First Middle Last home Address: --- Phone Number xomc Work Member's Interest Date of Birth Fall name. First Middle Last home Address: ---- Phone Number mmp _._ --------- Work-------- -- — --... Member's Interest Date of Birth -----------__--- ------ Full name Fust Middle Last Home, Address: Phone Number Member's Interest- --- DateofBvth -- — The managing partner will be Full.Narae The manager, proprietor or the agent in charge of the partnership's premises to be licensed: Full name First —M ddle Last __-- Home address__ Phone Nunber Home.._. - — --Work-- Date of Birth - — — --.---