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

Page 10A PLEASE TYPE OR PRINT ALL INFORMATION srArE ASSTGNED LrcENsE NUMBER /ldf- 3Z - d* -oo I ALL APPLICANTS ANSWER THE FOLLOWNG IADD PAGES AS NECESSARY] SOLE OVVNERS AND PARTNERSHTpS: Comptete this page in fu . LIMITED PARTNERSHIPS: All information about a general partner or partners ofa 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 parlner as it relate; to total ownership ofthe business entity to be licensed. coRPoRAT|oNS: 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. information on this Page, 1oA, wili identify all officers, direciors and stocl$olders holding one percenl or more ofthe shares ofthe respec{ive company. club li;nses musflist na;es of offlcers and directors and attach a current membership list. *****t********#*t***************t*t*****t***t********ttr****tt*********t*****rr**,rtt********t+********i* NAME OF CORPORATION OR CLUB COVERED BY CORPORATION OR PARTNERSHIP) Na ******* S PAGE (COMPLETE ONLY IF APPLICANT OR STOCKHOLDER IS A of individual (last name first ), stockholder, partner, officer or direclot. Last N e Street Address Number P.O. Municipality 7l-- zip State Social Security Numb", Date of Birth Home telephone numoer ( offic€ telephone number Area Exchange % of business owned or controlled Check position that applies: _ Number of shares _ Sole owner President _ Vice-President ___la:Trustee _ Manager _ Other (specify) Beneficiary _ rlner _ _ Secretary Agent _ _ _ Stockholder Treasurer ExeqJtor/Administrator _ _ Direclor Receiver ame of individual (last name flrst) , stoclholder, partner, officer or direc{or: I Last Name Home Street Address Number P.O. Box#_ Municipatity State zi SocialSecurity Number Date of Birth Home telephone number ( Office telephone number ( Area Exchange Check position that applies: President _ _ Number d % of business owned or controlled Sole owner y'f rustee _-dre-president. Manager Beneficiary _ Other (specify) Partner Secretary Agent Number of

osition that applies: President _ _ Number d % of business owned or controlled Sole owner y'f rustee _-dre-president. Manager Beneficiary _ Other (specify) Partner Secretary Agent Number of shares _ _ _ Stockholder a. Treasurer Direclor Executor/Administrator Receiver