Filing Letter to Board in Response to M Bennett Email with Exhibits 12 02 2024

Page I PLEASE ryPE OR PRINTALL INFORMATION STATE ASSIGNED LICENSE Nt]MBER lA6-9 -,ul - oct ALL APPLICANTS ANSWER THE FOLLOWNG S,1 DOES ANY INDIVIDUAL. PARTNERSH IP, CORPORATION OR ASSOCIATION OIEEEIEAN.IIE.AEPUEANI HAVE AN INTEREST DIRECTLY OR INDIRECTLY IN THE LICENSE APPLIEO FOR OR IS THE STOCK OF ANY yes srocKHoLoER HELo rN EScRow oR PLEDGED rN ANy wAy? _ lzfo IF THE ANSIVER IS 'YES,'ANSIVER THE FOLLOWNG USING A SEPARATE PAGE 9 FOR EACH INOIVIDUAL OR CORPORATION OF INTEREST, ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEOED, Name of lndividual (Last Name FiBt)or Corporation (Lasl Nam€, Firsl N6me, Middle lnitialor Colpolale Name) OR Social Secudty Number NJ Sales Tar Cerlificale ofAuhoniy Number_ Slrcel Address N0mber Street Name Municioelilv Po Bor * State zip Descnbe Nature ol lnteresi 92 DOES ANY INDIVIOUAL PARTNERSHIP, CORPORATION ORASSOCIATION HOLDANY CHATTEL IVORTGAGE OR CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FIJRNITURE, FXTURES, GOODS OR EQUIPMENT TO BE USED IN C9NNECTION vvlTH THE BUSINESS TO BE OPERATEO UNDER THE LICENSE Yes -jZ1No APPLIEO FOR? -- - IF THE ANSWER IS'YES,'ANSWER THE FOLLOWNG USINGA SEPARATE PAGE 9 FOR EACH INDIVIOUAL OR CORPORATION TO BE REPORTED, ATTACH A SEPARATE PAGE OF EXPTANATION IF MORE SPACE IS NEEDED' - - Name of lndividual (Le3l Name FiGl) or Corporation (Last Name, Filst Name, Middle lnilialor Corporate Name) _ OR Social Secudty Number NJ Sales Tar Cenrfic.te of Auinority Numbe, N6me Number Streel - MunioPaltty P.o. Box #- State ziP Descfloe Nalu€ of lnlorest 9,3 HAS THE APPLICANTAGREEOTO PERMITANYONE NOT HAVINGAN OW!ERSHIP INTEREST IN THE LICENSETO RECEIVE ORAGREEOTO PAYANYONE (BYWAY OF RENT, SALARY OR OTHERWSE)ALL ORANY PERCENTAGE OF THE GROSS RECEIPTS OR NET PROFIT OR INCOMI'ERIVED FROM THE BUSINESS TO BE CONDUCTED UNDER THE LICENSE APPLIEO FOR' -.IZ: NO -' - IF THE ANS\A/ER IS 'YES,'ANSWER THE FOLLOWNG USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPTANATION IF MORE SPACE IS NEEDED. -YES - Name of lndividual(Last Name Fid) orCorporation - lvliddle lnitial Last Name -- Sodal Seorily Numb6r - NJ SalesTax Ceruncale ofAuthodty Number- P.O. Boxr- Number - oR St€€t Name Munidpalrty- Stale zip - Describe Nature of lnleresl APPLICANTSTHATARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE

SalesTax Ceruncale ofAuthodty Number- P.O. Boxr- Number - oR St€€t Name Munidpalrty- Stale zip - Describe Nature of lnleresl APPLICANTSTHATARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 1OA, CORPORATIONSANO LIMITED LIABILITY COI\TPANIES CONTPLETE PAGE 10. -