Supporting Documentation · Jan 8, 2025
Exhibit A 2 Filing Application Amendment ECCC 101024
d8cb0f61db5a0087de4c2786b85055e4cfb897da9c8d6326f934a0247d58845bIndexed text · page 11
Show all pagesPage 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 0722.33. O15 001 ALL APPLICANTS ANSWER THE FOLLOWING [ADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Complete this page in full LIMITED PARTNERSHIPS: All information about a general partner or partners of a 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 of the percentage of each limited partner as it relates to total ownership of the 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 must have been reported on Page 10. Information on this Page, 10A, will identify all officers, directors and stockholders holding one percent or more of the shares of the respective company. Club licenses must list names of officers and directors and attach a current membership list. ereerees TEI III III I I I I II I II II I I III IIA cons Henn Hott ae NAME OF CORPORATION OR CLUB COVERED BY THIS PAGE (COMPLETE ONLY IF APPLICANT OR STOCKHOLDER IS A CORPORATION OR PARTNERSHIP): Essex County Country Club Name of individual (last name first), stockholder, partner, officer or director: Purcell Patric Last Name . «a First Name Middle Initial Home Street Address 131 Marion Drive Number Street Name P.O. Box # Municipality _ West Orange State NJ Zip__07052_- : an 2 Social Security Number_ 146. 9721 Date of Birth 12 pile Home telephone number (__973__)__ 204 -___ 1498 Area Exchange Number Office telephone number (_ 973) _731 -_ 1400 Area Exchange Number ‘% of business owned or controlled Number of shares Check position that applies: Sole owner Partner Stockholder President Vice-President Secretary Treasurer Director Trustee Manager Agent Executor/Administrator Receiver Member, Board of Governors Beneficiary x Other (specify) Name of individual (last name first) , stockholder, partner, officer or director: Lavoie Justin Last Name First Name Middle Initial Home Street Address 14 Meadow Lane Number Street Name N P.O. Box # Municipality __ VeTona State Zip 07044 ee ad 1974 Social Security Number 020 -_ 52 -__ 7568 Date of Birth 6 ;_ 12 Home telephone number ( 973 ) 571 ._9397 Area
dow Lane Number Street Name N P.O. Box # Municipality __ VeTona State Zip 07044 ee ad 1974 Social Security Number 020 -_ 52 -__ 7568 Date of Birth 6 ;_ 12 Home telephone number ( 973 ) 571 ._9397 Area Exchange Number Office telephone number (_973 )_731 .__ 1400 Area Exchange Number % of business owned or controlled Number of shares Check position that applies: Sole owner Partner Stockholder President Vice-President Secretary Treasurer Director Trustee Manager Agent Executor/Administrator Receiver Beneficiary ___X Other (specify) __ Member, Board of Governors
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