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10/17/2007 t`1ED 15:16 FAX 61278 23302 Canon 6670 <br />PART II <br />INI)NIDUaL <br />(Io be mmpitled byau bnlividoal owne) <br />zl,div';dual <br />Full mune rust i Lddle <br />Phone Number <br />— <br />. dill SS '�rli fa,S Phone Nunlbcf_..__. <br />__ <br />ll,11eofl3ulh -- — <br />Lasl <br />,tanager, proprleCor or other agerri in charge of dle individual ovy'ncr's premises to be licensed <br />Full [1,11110 ddlo <br />Dd.1C of 13irdt-_..___... ....__._._._— <br />tlome Address: -- --- <br />lone Number ll0l a <br />Wo,k -- -- <br />The managing partner vvrdI be <br />Full N5n1c <br />The rn2uager, proprietor or flic agent in chane of the partnership's premises to be licensed: <br />Full 11:1111c, First Middle Lnsl <br />1101ile aidl'es'S - <br />Phone Nuulbe.r Hon --....__ _.___ __'--.._.... <br />0022/030 <br />21 <br />5 <br />PARTNERSII'IP <br />('I �b !n: anm;51c1oA by a I'anncr) <br />1.Ist c;wlt nlombel' <br />of the I),-lFj19 lSlltt) 911d <br />the Il embCl'':i <br />hullImmc <br />llr, <br />IlllerCSt <br />"Middle <br />Loss <br />ltnittcAddre>S�. <br />_---- ---- <br />PhoncNunll>cr <br />Ilon. <br />__-__ --- <br />— — <br />lVo k <br />1✓1UOlbcL31111C1'Ctil <br />---- �—�-- <br />Dutc of 13ir111 <br />—_ <br />_. <br />_--..._...__ <br />Full name <br />ITi rsl <br />—_ <br />Midlilc <br />Last <br />11111„e Addles: <br />'lone Nmnber <br />hale <br />---- <br />vorl...._._._ <br />I�`i CIl1UCf'�S llllel't',5( <br />.- _._.._-.-___— <br />Dake of Birth <br />- ��---- <br />Full nluue <br />F5'sl <br />!sAitldlc <br />Last <br />'.Ionc <br />---- <br />-- <br />Vlolk <br />1:'1e111JC1'S 111(CI (:Si <br />Dale of Bull) <br />Full manic <br />Fin!----- — <br />Mid<'Ic <br />Last <br />Home Address'. <br />_ --- .. -- - --- <br />— ----- <br />----' <br />Phone <br />lone Number <br />I lolnc <br />- ------ <br />a <br />I\-TCtlll)81'S [Il tel'L'gL <br />------'--"— <br />t?0.te of Ruth <br />�-- <br />The managing partner vvrdI be <br />Full N5n1c <br />The rn2uager, proprietor or flic agent in chane of the partnership's premises to be licensed: <br />Full 11:1111c, First Middle Lnsl <br />1101ile aidl'es'S - <br />Phone Nuulbe.r Hon --....__ _.___ __'--.._.... <br />0022/030 <br />21 <br />5 <br />