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

Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER Uo.r-33-oq-ooI ALL APPLICANTS ANSWER THE FOLLOWING IADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Complete this page in full. LllrlTED PARTNERSHIPS: All information about a general pa(ner or parlners of a limiled partnership must be reported, Mether the general partner is an individual or a corporation. A list of the names and addresses of all limited partners must be submitted as an attachment to this application with an identification ofthe percentage of each limited partner as it relates to total ownership of the business entity to be licensed. CORPORATIONS: All corporation applicants or licensees and any corporation that has an ownership interest in the corporation under license or lo be licensed must have been repo(ed on Page 10. lnformation on this Page, 10A, will identity all officers, directors and stockholders holding one percent ormore ofthe shares ofthe respeclive company. Club licenses must list names of officers and directors and attach current membership list OF CORPORATION OR CLUB COVERED BY THIS.PAGE (COMPLETE ONLY IF APPLICANT OR ST OCKHOLDER IS A RPORATION OR PARTNERSHIP) fl^irvh't (J c.r^ rr/vtr U"L rlime or inEviouar lrasi nime nis|, stoctnoEer, p cer ireclor. Last Name Home Street Address lnitial Number P.O. Box # State Municipality zip oaeoraia SocialSecurity Number Home telephone number ( Number EXCnange Office telephone number Exchange Number Area Check position that applies: _ Vics Presid€nt ]u"n"n", --1r-o* other (spedfy) Beneficiary _ Name of individu Partner Sole owner l4resident / Number of shares % of business owned or controlled Stockholder _ Secretary _Agent Treasurer Director Executor/Admin istrator Receiver (last name lirst) , stockholder, parlner, offcer or direclor: - O\itial Last ome Street Address Number P.O. Box # _ Municipality zip Dete of Birth Social Security Number Home telephone number Areq" Etr4hqnge Area Exchange Number Office telephone numbe o/o of business owned or controlled Check position that applies: _ Sole owner Number 0 Partner _President _Vice-President -y(secretary Manager tArustee _ Agent Other (specify) _ Beneficiary - Number of shares o Stockholder Treasurer _ Executor/Adm in istrator Direclor Receiver -