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10/17/2007 WED 15: 17 PAX 6127823302 Canon 6870 <br />PART 111 — PERSONAL INFORMATION <br />(11 of SL Anthony liquor & hVine License kp III caHoll <br />This section AM be wjAcled by each MCA paqncr, officer; manager, proprietor or other <br />ago( in charge, and each person A0 by (:onubintd ownciship or control has all ifflelcet in a <br />cu: pola[ioll ur aSSOCnluiorl in excess of five percent (54t/0) <br />FT, -I -nu Nance <br />,Rebecca Robbins Tilden <br />J)uu of 14/23055 Place of 13nt1, Tort Carson CO <br />I-- --- I <br />Q11'rent Home AdcKs <br />117504 El Monte Circle <br />Other Names Used/Aliasaura ,talus l <br />S�nglcx Married 1 :0 1 ced <br />— <br />Spowe's Aw New James Clark Tilden <br />llatco - I — --- - - -- - -- `— - -- --- - I <br />nliqh_j 10/31/55 1 PiaccofBirth i Ames. IA <br />Home Address The above <br />------- ------- <br />Arc you or your shouse a Qswred vowo <br />Rcodenwo Address for Poccong 10 Ynw: <br />See Exhibit B attached <br />C"ity, sknro,7ij�:.- <br />Name,Address and Phone Nurllbcr <br />See Exhibit it attached <br />Applicant . X% , No Spouse - Xycs f\! <br />Loclujon: Kansas Location: Kansas <br />Usand Partners f6l' PrccC—dh-r, <br />10 Years: <br />cssc�s and Phone h4wobw o and Partners for Picceding 10 )7 ears: <br />See Exhibit B attached ------ <br />has applicant I -()-I [S�7-0-r m'siblino or child been convicted of any, Drum: of <br />-- <br />violation of any ordinance other than haf5c? If so, please furnish informition as to the time, place <br />and offense for which convictions were lead: <br />No <br />Name, home Mesa and Nowess address of each Person Ao is engaged in Minnesota in the — - <br />business of selling, manufacturing or distributing liquor and who is neater to A to the aNAM or <br />spouse drain second cousin, As% of the We or halkhod, computed by the rules of civil law, <br />of who is a brother -in -lav, or sister-in-law of to applicant or the atlolicank R)OUSC. <br />Mi It t2rY Set V I cc (Upon request, you may be asked lo provide chAuge papers) I X 'yes <br />0025/030 <br />8 <br />24 <br />