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

PLEASE TYPE OR PRINT ALL INFORMATION Page 10A STATE ASSIGNED LICENSE NUMBER ALL APPLICANTS ANSWER THE FOLLOWNG IADD PAGES AS NECESSARYI SOLE OWNERS AND PARTNERSHIPS: Complete this page in full LIMITED PARTNERSHIPS: All information about a general partner or partners ofa limited partnership must be reporled, whether the general partner is an individual or a corporation. A lisl of the names and addresses o, all limited partners must be submitted as an attachment to this application with an identification of the percentage of each limited partner as it relates to total ownership of the business entity to be licensed. CORPORATIONS: All crrporation applicants or licensees and any corporation that has an ownership interest in the corporation under license or to be licensed must have been repo(ed on Page 10. lnformation on this Page, 10A, will identify all officers, directors and stockholders holding one percent or more ofthe shares ofthe r€spec{ive company. Club licenses must list names ofofficers and directors and attach a cunent membership list. ******r****************t****t********t******************tt*t*++tt*t***************l*t**********************t**r**** NAME OF CORPORATION OR CLUB COVERED BY THIS PAGE (COMPLETE ONLY IF APPLICANT OR STOCKHOLDER IS A CORPORATION OR PARTNERSHIP): Name of individual (last name frst), slockholder, partner, officer or direclor: Street Name Number P.O.Box#_ Middle lnitial First Name Last Name Home Street Address State Municipality zip NumberHome telephone number (-)-- -Offic€ telephone number (- Date of Birth - Social Security Area - Area Exchange Number Exchange Number 1 Number of shares % of business owned or controlled Check position that applies: owner Parlner Stockholder President Vice-President Secretary Treasurer Director Executor/Administrator Receiver Truslee -SoleManager -_ Beneficiarv Olher (specify) -Agent Name of individual (last name Iirst) , stockholder, parlner, officer or direclor: Street Name Number P.O.Box#_ Middle lnitial First Name Last Name Home Street Address - State Municipality zip Number(-)-Home telephone number Area -Offica tglephone number ( Ar€a - Exchange ) Number Exchange Number _ _ - Sole owler President _ Trustee - Vice-President Beneficiary Other (specify) - - -l - Number of shares % of business owned or controlled Check

- Exchange ) Number Exchange Number _ _ - Sole owler President _ Trustee - Vice-President Beneficiary Other (specify) - - -l - Number of shares % of business owned or controlled Check position that applies: I DaG of Birlh Social Security Manager _ _ _ Partner Stockholder SecEtary Treasurer Director Agent Executor/Administrator Receiver