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

Page 1OA PLEASE TYPE OR PRINT ALL INFoRMATIoN srArEAssrGNED Lrceruse Nurvrasn /051- 3 et _o" I ALL APPLICANTS ANSWER THE FOLLOWNG IADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Comptete this page in full. 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 identifcation ofthe percentage of each limited partner as it relates to total ownership ofthe business entity to be licensed. coRPoRATIONS: All corporation applicants or ljcensees 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 identily all officers, directors and stockholders holding one percent ormore oftheshares ofthe respeclive company. Club licenses must list names of officers and direclors and attach a current membership list. ************l}**t********!r*t*'r***t**it*********t**********t*******t***********+******i1,.******i*******r************* NAME OF CORPORATION OR CLUB CORPORATION OR PARTNERSHIP): BY THIS a ame of individual (r ast name first ), stockholder, partner, Lar PLETE ONLY IF APPLICANT OR E OCKHOLDER IS A (, t or director; Last Name me Street Address Number P.O. Box#_ stat- Municipality zip Social Security Number Date of Birth Home telephone number Offlce telephone number % of business owned or controlled _ _Sole owner _ partner _ President _ Vice-president _ Secretary _ Trustee ,Manager _Agent Check position that applies: _ _ ........._ Beneficiary Number of sharcs Stockholder Treasurer Direclor --ylOtner Gpecifyl Name of individual (last name first) , stockholder, partner, officer or director: Last Name Home Street Address First Name Number P.O.Box#_ Municipality Middle lnitial Street Name State Zio Number_ -_ Date of Bidh Home telephone number (_)_Area Exchange Number Office telephone number (_)_ Area Exchange Number % of business owned or controlled _ Number ofshares Check position that applies: _ Sole otvner _ Partner _ Stockholder _ President _ Vice-president Secretarv _ Treasurer _ Trustee _ Manager _Agent _

r % of business owned or controlled _ Number ofshares Check position that applies: _ Sole otvner _ Partner _ Stockholder _ President _ Vice-president Secretarv _ Treasurer _ Trustee _ Manager _Agent _ Executor/Administrator Beneflciary (specify) Other _ _ _ Social Security Director Receiver