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

Page I PLEASE ryPE OR PRINT ALL INFORMATION 2020 .33 STATE ASSIGNED LICENSE NUMBER _ 027 _002 ALL APPLICANTS ANSWER THE FOLLOWING 9,,1 DOES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION THER THAN THE APPLI HAVE AN INTEREST DIRECTLY OR TNDIRECTLY lN THE LICENSE APPLIED FOSLOR lS THE STOCK OF ANY Yes ^^ No STOCKHOLDER HELD lN ESCROW OR PLEDGED lN ANY WAY? IF THE ANSWER IS 'YES," ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION OF INTEREST, ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED, - Name of lndividual (Last Name First) or Corporation (Last Name, First Name, Middle lnitial or Corporate Name) oR Social Security Number NJ Sales Tax Certifcate of Aulhority Number Street Address Number il - MuniciPality P.O. Box # State zip Describe Nature of lnterast 5,2 DOES ANY -INDIVIDUAL. PARTNERSHIP, CORPORATTON OR ASSOCIATION HOLD ANY CHATTEL MORTGAGE OR CONDITIONAL BILL OF SALE OR OTHER SECURITY INTEREST ON ANY FURNITURE, FIXTURES, GOOOS OR -TO -BE USED IN CONNECTION WITH THE BUSINESS TO BE OPERATED UNDER THE LICENSE EQUIPMENT Yes xx No APPLIED FOR? IF THE ANSWER IS'YES,'ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIOUAL OR CORPORATION TO BE REPORTEO. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEOED. Name of lndividual (Last Name First) or Corporation (Last Name, First Name, Middle lnitial or Corporate Name) - - Social Security Number OR - NJ Sales Tax Certificate of Authority Number Street Address Number - P.O.Box#- Street Name Municipality - State zip Describe Nature of lnterest HAS THE APPLICANT AGREED TO PERMITANYONE NOT HAVINGAN OWNERSHIP INTEREST IN THE LICENSETO RECEIVE OR AGREED TO PAY ANYONE (BY WAY OF RENT, SALARY OR OTHERWISE)ALL OR ANY PERCENTAGE OF THE GROSS RECEIPTS OR NET PROFIT OR INCOME DERIVED FROM THE BUSINESS TO BE CONDUCTED NO YES UNOER THE LICENSE APPLIED FOR? ]L- IF THE ANSWER IS'YES,'ANSWER THE FOLLOWING USING A SEPARATE PAGE 9 FOR EACH INDIVIDUAL OR CORPORATION TO BE REPORTED. ATTACH A SEPARATE PAGE OF EXPLANATION IF MORE SPACE IS NEEDED. - Name of lndividual (Last Name First) or Corporation Middle lnitial First Name Last Name OR Social Security Number NJ Sales Tax Certiricate of Authority Number Street Address Number Street Name Municipality P.O. Box # State zip Describe Nature of lnterest - APPLICANTS THAT

Name OR Social Security Number NJ Sales Tax Certiricate of Authority Number Street Address Number Street Name Municipality P.O. Box # State zip Describe Nature of lnterest - APPLICANTS THAT ARE SOLE PROPRIETORS OR PARTNERSHIPS GO TO PAGE 1OA, CORPORATIONS AND LIMITED LIABILITY COMPANIES COMPLETE PAGE 10. -' -