City Council Agenda and Packet 1973 11 13

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DRL 404-A Rev 9/73 STATE OF COLORADO, DEPARTMENT OF REVENUE LIQUOR LICENSE APPLICATION ADDEHUUM Date_cos1.91,c_15.9 1973 1. Corporate Name Indiv. ownership .rnics ±D iva" 2. trade Name �� Drug Stagy — 3. Address T]Hain 8t. Louiev • Colo 4. State L quor tense . o. ,« e,..r_ -rr.j to o solo or ci ange 5. List below the officers or directors of the corporation: Date Name Hare Street no. S City of Birth President: Vice Pres.: -;Treasurer: �_ Secretary: + • : P nager: 6. DIRECTORS: List all Directors (at ?east 3 are required by Law) DOOM • Name Nome Street No. I City of Birth . 7. List all stockholders owning or controlling 10% or more of the capital stock of the corporation. (Include actual owner or pledgee.) Use separate sheet if needed. Percent of Date Name Home Street No. 8 City Stock Owned of Birth � � l) so J e- ` 8. Have any of the above named officers or stockholders ever been convicted of any felony or violation of any liquor law in any Federal or State court of record in the State of Colorado or any other state? If so. explain fully 9. Do any of the persons listed in paragraphs 5 and 6 above now own any stock or have an interest, financially or otherwise, in any other alcoholic liquor or fermented malt beverage license in the State of Colorado?. _--,. ..s..) . If so, explain fully by separate letter. 10. Does any person, firm or corporation have a financial interest, evidenced by loans or equity ownership in the business for which this license is requested? If the answer is yes, state names and addresses and amount. 11. Date of filing last annual corporate report to Secre • ry o tate. Sign here: T . e..� ame By: 11/w11 ri �_ �l�'•�. � esl ) oi �r...-- Date By: Title APPROVED BY STATE LICENSING AUTHORITY: Date li tTe