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no <br />Individual <br />Full name <br />Home address: <br />Phone Number <br />Business Address <br />Phone Number <br />Date of Birth <br />PARr 11 <br />AY V.L I v W V ilii <br />(To bo cgn.pleted by as Individual Owner) <br />l nt Middle Last <br />Manager, proprietor or other agent in charge of the individual owner's prernises to be licensed <br />lull name pint Middle Last <br />Slate of Birth <br />Home Address: —_ <br />Phone Number lioa.c Work <br />PARTNERSHIP <br />(1b be co::xplete.d by a Panner) <br />List each member of the partnership and the member's interest <br />Full name Plast Middle Fast <br />ISome Ad«ess: <br />Phone Number home Work <br />Member's lirterest <br />Date of Birth <br />dullualne T`i'le �.T Middle Last <br />Home Address: _ <br />Work <br />Phone Number <br />Member's Interest <br />Date of Birth <br />--------._ .—......_ —..__------'_'------ <br />Dill nameThat A4.iddlc Last <br />Home Address: <br />_ <br />Phone Number 1_omc------'— .—_—_ Work <br />Member's Interest <br />Date of Birth —_--„ _----- — <br />lull naive Fust M delle Last <br />Home Address: -----._.___-- <br />Phone Number <br />Members Interest <br />Date. of Birth — — --- _.------.---_�. <br />The managing partner w ll be <br />Ful! Name -- __-- ---- <br />The manager, proprietor or the agent in charge of the partnership's premises to be licensed: <br />Tull name Fust Middle Last -- <br />Home address __ _---.--- <br />Phone Number Tiom___e Work <br />Date of Birtlr ....__—. -- <br />