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

Page '10A PLEASE ryPE OR PRINT ALL INFORMATION sTATEASsTGNEDLTcENSENUMBER //0i-- 33 --la't- oo t ALL APPLICANTS ANSWER THE FOLLOWNG [ADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Complete this page in full. LIMITED PARTNERSHIPS: All ioformation about a general partner orpartnersofa limited partnership must be reported, whether 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 ofthe 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 to be licensed musl have been reported on Page '10. lnformation on this Page, 10A, will identify all officers, directors and stockholde[s holding one percent or more ofthe shares ofthe respeclive company. Club licenses must list names of officers and directors and attach a current membechip list. ***l*********************************t**t*********t*t********!r*ff*+**********t***************t*:r****,1************* NAME OF CORPORATION OR CLUB C OVERED BY THIS AGE COMPLETE ONLY IF APPLICANT OR STOCKHOLDER IS A CORPORATION OR PARTNERSHIP): Name of ind C dual (last name first), stockholder, p , officer or direclor Last Name ome Street Address Number P.O. Box # Municipality State zi Social Security N Date of Birth Home telephone num ae Area Office telephone number (_)_-_ Area Exchange Number Exchange Number % of business owned or controlled Number of shares _ PrBsident Check position that applies: Sole owner Vice-President Manager --a Beneficiary _ -lz1ruslec _ - _ Partner _ Secretary _Agent Stockholder Treasurer Direclor Executor/Administralor Receiver Other (speciry) Name of indjyidlal (last name fiEt) , stockholder. partner, offcer or dire-clor: b" o.n i,ch .L k b F -7,n|ffu| Last Name Street Address Number P.O. Box # Municipality State zip DateofBir Socialsecurity Numbe Home telephone numOer Office telephone number Area Exchange Number % of business owned or conlrolled _ President L/ f ruslee --/. _ Beneficiary _ - Check position that applies: Number of shares Sole owner Vlce-President Manager Other

umber Area Exchange Number % of business owned or conlrolled _ President L/ f ruslee --/. _ Beneficiary _ - Check position that applies: Number of shares Sole owner Vlce-President Manager Other (specify) Partner _ _ Secretary Agent _ _ _ Stoclholder Treasurer Direclor Executor/Administrator Receiver