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Individual Frill name IIome address: Phone Number Business Address Phone Number Date of Birth PART SI UNDWMAL ('Po be complGV-d by au Individual Owner) First Middle Lest Manager, proprietor or other agent in cha ge oi'the individual owner's promises to be licensed Full native Fist Nsldle r act Date of Birth ._._— ---- -- ---- -- Home Address:..-- PhoueNumber kIomc. Won VAR-I'NF SfIIry (ro be wmplcted by aPocr) List cans member of the partnership and the member's interest Full name, bust M;adle t as I! orne Address: -._._ _—.. PhoneNutnber _ Howe __. �UOI Member's Interest — — ..____.... _.__—__._...._____ Date of Birth Full name Fast Middlo 1,oa Home Address: Phone Number Hot to work D4embce's Interest _ _ __...__ ——..---- — — Date of Birth _ --- — FuU name Pirsr Ndddlc Last Home Address: -..._...---- Phone Numberflame ...._..------ work ----------._--- — Member's hiterest --------'----------------- .-_....--------' Date ofBiiib --------------�.--.'--'_----------------- Pull name F;rst --�-- ---- Middle Home Address:--- Phone Number Hock work Member's Interest -------_—___'—_--- -------- —_— Date of Bird: -------- Tile managing partner will be Full -.,a.-ne ------ -- —....' The manager, proprietor or the agent in charge of the partnership's premises to be licensed: Full name Pirst ._.------Middle Home address ------- . Phone Number _ ___ Homo -------_-- Date of Birth