Supporting Documentation · Jan 8, 2025
Exhibit A 1 Amendment application filed 4 10 24
d0597015545aa2f0bd7182b46c36971276e239813d9049ea6efb54ad672f2078Indexed text
l Home Street Address Y 7 Number ldwick Soa"? a P.O, Box # Municipality _Waldwicl State J Zip 07463 _ OP ee ete rer 78 0561 1 1984 Social Security Number__142 - = Date of Birth I Home telephone number (_272__)__390 _ 0600 Area Exchange Number Office telephone number ( - Area Exchange Number % of business owned or controlled Number of shares Check position that applies Sole owner Partner Stockholder President Vice-President x Secretary Treasurer Director Trustee Manager Agent Executor/Administrator Receiver Beneficiary Other (specify)
Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER __0722._ 33 001 ALL APPLICANTS ANSWER THE FOLLOWING [ADD PAGES AS NECESSARY] SOLE OWNERS AND PARTNERSHIPS: Complete this page in full. LIMITED PARTNERSHIPS: Alll 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. JESS III III II III III ITI I III III II III IIT OTT I IIIS SIS III I I I III IS SII ISIS IIIS I ISS ISS SSSI SS I ISIS ISIS SSSI SA. 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: Kelly Joseph Last Name First Name Middle Initial Home Street Address 8 Danbury Ct. 1404 Number Street Name NY P.O. Box # Municipality __ Suffern State Zip 10901 ere Se man Al 74 452: 8 21 1968 Social Security Number ee - - Be Date of Birth df; h Home telephone number (_973__) - jkelly@essexcountycc.com Area Exchange Number Email address: __) és : Office telephone number ( ) = 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 X_ Manager Agent Executor/Administrator Receiver Beneficiary Other (specify) Name of individual esp-naine i , Stockholder, partner, officer or director: onzalez, Willy LastName 5 Westwood Dr. Noitti Name Middle initial Home Street Address Number Street Name P.O. Box # Municipality West Orange State NJ Zip 07052 __ 21 Social Security Number__148__- -__ 7788 Date of Birth
Name 5 Westwood Dr. Noitti Name Middle initial Home Street Address Number Street Name P.O. Box # Municipality West Orange State NJ Zip 07052 __ 21 Social Security Number__148__- -__ 7788 Date of Birth 9. ;_ 30 /__ 1983 Home telephone number (273) _ 640 -_ 9642 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 X_ Manager Agent Executor/Administrator Receiver Beneficiary Other (specify)
Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 0722... 33 001 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. JORIS EIS III III III I TORII III TI TI I II I I III IIIS III IS SSSI SSSI SSSI ISIS IIIT OD IIIS I IIS SSSI IS ISS SII SI SSSI SSSI SSS ISIS S SA 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: Penaherrera David ae jkast ame 18 Pearl Street First Name Middle Initial Number Street Name P.O. Box # Municipality _ Passaic state NJ. Zip 07055 - Sotial Seourity Number Sho. 99> 2 8881 Date of Birth 5 ;__16 jo doe Home telephone number (__201 __) 702 4156 Area Exchange Number Office telephone number ( ) - 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 ____ Other (specify) Name of individual (last name first) , stockholder, partner, officer or director: Gonzales Leandro ee sash Name 104 Davis Ave. First Name Middle Initial Number ___ Street Name P.O. Box # fMuniefgaity:_ =eartison State Ny Zip 07029 _- Social Security Number_150. «19 =~ —8637 Date of Birth _ 10 ;_18
ee sash Name 104 Davis Ave. First Name Middle Initial Number ___ Street Name P.O. Box # fMuniefgaity:_ =eartison State Ny Zip 07029 _- Social Security Number_150. «19 =~ —8637 Date of Birth _ 10 ;_18 ;__1996 Home telephone number (___ 201) 519 - 4490 Area Exchange Number Office telephone number ( ) - 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 __X_Manager ____ Agent ____ Executor/Administrator ___ Receiver Beneficiary Other (specify)
Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER __0722. _ 33 001 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. FEISS II III OI III III III III III I I I I II I II I I IIT OS IOI IIIS OD I IIIS SSIS ISI ISI II I AS SIS IIS SISOS OS I II SSI ISSA 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 atric Last Name z «a First Name Middle Initial Home Street Address 131 Marion Drive Number Street Name P.O. Box # Municipality _ West Orange State NJ Zip 07052 - 29 Social Security Number _146 ees -_ 9721 Date of Birth__12 / )_1966 Home telephone number (__973 _) 204 2, 1498 Area Exchange Number Office telephone number ( ) E 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 Bariliclary X other (epacity) Member, Board of Governors Name of individual (last name first) , stockholder, partner, officer or director: Lavoie Justin Force anda cee 14 Meadow Lane First Name Middle Initial Number a Street Name NI P.O. Box # Municipality cone) State Zip 07044 Social Security Number_920 52 -__ 7568 Date of Birth «© s_'12 joists Hemetelephoné number
14 Meadow Lane First Name Middle Initial Number a Street Name NI P.O. Box # Municipality cone) State Zip 07044 Social Security Number_920 52 -__ 7568 Date of Birth «© s_'12 joists Hemetelephoné number (923° 5.27 -_9397 Area Exchange Number Office telephone number ( ) 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
Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER __0722._ 33 001 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. JESS IIIA I IOI II IOI TI II IIIT IS I IIIT III III I II I TI SI TT II II III IIS SSSI SSS SSIS ISS ISSIS SSIS SSS IIIS SIAN. 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: Rakela Esteban Last Name ‘ irst Name Middle Initial Home Street Address 931 ‘Washington Stree! Number Street Name P.O. Box # Municipality Hoboken State NJ Zip 07030 - 1977 Social Security Number__476 ‘04 -_ 5071 Date ofith 9 oy 19 Home telephone number (_ 201 ) 238 a 2375 Area Exchange Number Office telephone number ( ) : ‘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 % _ Other (specify) Member, Board of Governors Name of individual (last name first) , stockholder, partner, officer or director: Murzenski Michael LastName 102] Grand St, PHA First Name Middle Initial Home Street Address Number Hobok. Street Name P.O. Box # Municipality siecsiabd state_NJ Zip 07030 ss 1969 Social Security Number _141. -_ 66 -__ 6182 Date of Birth? / / Home
First Name Middle Initial Home Street Address Number Hobok. Street Name P.O. Box # Municipality siecsiabd state_NJ Zip 07030 ss 1969 Social Security Number _141. -_ 66 -__ 6182 Date of Birth? / / Home telephone number (_291 )__ 424 -__ 3154 Area Exchange Number Office telephone number ( ) 2 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
Page 10A PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER __0722. 33 001 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. JESSE OS SSSI SII III III III I I I TO I TOI I II III IO I II TT I OT I III III III III SOS III SII ISIS SSIS IIIS III IIS SASSI III ISIS IS ISA. 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: Brown Jeffrey Last Name First Name Middle Initial Home Street Address 3 Olde Woods Lane Number A Livia Name P.O. Box # Municipality __ Woodcliff Lake State NJ Zip 07677. ; 80 5522 4 18 1981 Social Security Number 148 : Date of Birth i / Home telephone number (_ 201) __ 832 _ 1995 Area Exchange Number Email address: Office telephone number ( ) 2 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 Name of individual (last name first) , stockholder, partner, officer or director: Klinger Daniel Last Name First Name Middle Initial Home Street Address 2 Ely Ct. Number Street Name P.O. Box # Municipality Livingston state__NJ RSENS TESTO 58 1967 Social Security Number_219 -__5918 Date
File revisions (1)
- Sep 29, 2026
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