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• ,..„,.:. r• ....,_.. . . „.„•:::,,-..• .• . ,.:• „T... -:.-,,,,,,,,, girr..,•.,-. -,- <br /> STATE Of COLORADO . <br /> ORARTHENT Of REVENUE <br /> intl./CATION AE KIxM ?OR A Ltepoit L1(ZNZ f <br /> T::is ;application Addendum mnsr he filled out completely and filed with the <br /> .Ippl k at tun. <br /> No license will be issued until the Applicatinn and the Application Addendum <br /> has bi•.'n approved by the respective Licensing Authorities. <br /> All Answers Hunt Be Printed In Ink or Typewritten. . <br /> 1. Nene of Applicant(s) *&4 • LAtL& ci r i` • <br /> Business Tel. No i „O <br /> 2. Trade Bloat Ei9 SL IJA1 - <br /> 3. Address of place to be licensed <br /> 4. City or Town _ County 1r0E4 /Q <br /> p - . <br /> S. Do you have legs possession of the premise ? <br /> 6. Are the premises owned or rented? Q /., If rented,from whom? <br /> 7. Effective date of the lease Expires <br /> S. Do you or any members of your fatly have a direct or indirect interest in any other <br /> Colorado Liquor License? (Such interest include any interest, loam, etc.) If this <br /> answer is yea, explain in details Yes 110 <br /> 9. Does any person,partnership, firm, have any interest (financially or other) either <br /> by loans or equity ownership in the business for which this license is requested? If <br /> the answer is yes, state names and addresses and amount of such (financial) interest <br /> T.. No, /Ile <br /> (The following affidavit to be signed and acknowledged by individuals and each member of <br /> partnerships or firms) <br /> STATE OF COLORADO <br /> County of <br /> and ,, being by me first duly sworn, if for himself,deposes <br /> and says; that he is the applicant above named; or that he is of the <br /> above named corporation; that he has read the foregoing application and that he knows <br /> the contents thereof, and that all matters and things therein act forth are true of hie <br /> own knowledge and he agrees to conform to all rules and regulations promulgated by the <br /> State Department of Revenue in connection therewith. <br /> Subscribed and sworn to before me Individuals and all members of partnership <br /> o sign he e: <br /> this A,I day of <br /> 4.1 �.�- •p�►,� pL 162. <br /> i l92: <br /> (S(i•nq rc of Lary Public <br /> Attach Seal <br /> lty Commission Ekpire$Y t4 _ISSf011 CS eS $C ltltbLA ZRj <br />