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MPH.4 1..1•mitt) • • <br /> sTAU OF COLORADO • • <br /> DEPARTMENT OF REVENUE/1.104)0A ENFORCEMENT <br /> • <br /> NDVi9UAL HISTORY RECQRO . _ __ ^r <br /> To be cdot pietad by crab individtrel eppiieant,each wine and over 61,:limited partner of a partnership. each officer.director,end over 6% <br /> ctotidtoldir of a eorparetion,end eve meow of the applicant. <br /> N� , .l 1,. 7 , .. <br /> Th.:bidividwai Niaaory Noosed provides basic information%which is necessary for the liatf»fng authorities';nve tipation.ALL questions must be <br /> antwer,ed in their r RY anew you;Ne sift be checked for i s tr ish:Inns.A deliberate falsehood wit!j►cpardiae tfas awilmetien <br /> at mode Malhoad�i anlMthe le"Meows remeedire the eMnectat and repltatNn of tM <br /> applicant. <br /> - <br /> t flr (WWI , tiK wily Member:� _ <br /> 7 'Pel wN Nino• , onitWfao a.A4 0 As tnu∎Oen rts•r.e•n.:4*$m4•SIc <br /> t ( i hat • f I 1 . <br /> • t: -"s. t: 1$' •W ye C ' , Moos. Do you Awe a C•f•ra•o Dr...e,I L, .AM7 If"Tis'�.alro number: <br /> .L rr l ft ..-rQu G1:t!i Willie NYI$ 9NO ' 198.7/0, <br /> 6 fMlinION 10 �+At...c t. loot*. o7•40Tr tr cor.Nrra rfrleerr4tr•ct•• Ita:riP 01wr Or rnenrN+? <br /> I , J 1 F. <br /> r i '-�• 1114(I11.• ' . • � •CI•f'y M ••c•• •••eam• •utltan•.na Stock Ownam <br /> II if frlrtar Maio wli.Mtw - Percent of Iarinota tso•rrtlf.uvta O*►ned <br /> QOMNIRIAI. 7LIIMiTIO _ <br /> -9 Ae•iittfltt•A4 i $S IIWWM1 On!*ur*bM:iltylRate/h.o) <br /> • I i - i COI • o 00;16 <br /> 1. I row - I Mile/. r•qo Whom <br /> 1aOw04110 QwaNTro <br /> 1 l M041ine A4.ae11,It p.tf.•eltt aerie Rsa O•nti <br /> 12 NNaius•1 Pr Sot•inror 1 .Type o $us•Aota O fmo°ovment <br /> iRe #61.4.ro n _ <br /> ,4 AHrr•s•of 1.~44‘pews a 'vas. wrest ale*umber/via'st•te/anal <br /> 6/0 Yrltirk ov s v' iie, aelo?' _ Pop e' - <br /> Ires•r•I'sag's . Is Hems T01•00000, Sus,nsasTelaohon•- <br /> IIi f! 4 -Y 1 . I i / <br /> 1? • • ufh I 141V of Brno <br /> del- ethler <br /> 15 U it+ten If wSIw'$d ae4.1tIM w+tere: When. hams of U.$ O.ur:N Cowl: <br /> Was QNO I <br /> N•IWafia•i,M C•VIH.ca1 N. Data of Comfiest* If s•+alien,awe Alien's Flee•strat,on Cs.d No- t romanont F/siosrtoo Cog p•.: <br /> r9 tM IaW1 - 'la. if MOuM s a w4Mk*fw,I ma San narne: <br /> hw asrie? <br /> /I a 1I • S <br /> )1 100t.a••1 Dale• Snot Ilan of Meth' I <br /> ' s / . <br /> 2J If$O1.■r•s.•Mae a4iro11 is•.ffrMr Man yours.nit 141.* lslriat and Pw''3$'-cIry/sun riw) <br /> K <br /> d J Wise t.Nap Mar*••• �IMt yr. Occ • nton: • <br /> • I!' rr eat : r1 ' f A`f . . rrc ' 14 11 <br /> A+MrM of...oat sonoNrr <br /> 4 a r / f / <br /> l but ow nonage•l all,Naives.r•rft•M it law bower urtIystry.S.r.n>the.. <br /> • •'airs• Location of Implpya►: <br /> it / _ • / <br /> a. t ii / a �� 1 U/ <br /> 'Plea ••sutra T'aI •t•YOw Locet,on 0 •mplOyr. <br /> LI flir _O-Cid C e r S / W a ii .fir , - • - 14/ . <br /> •• Q.alonl i.0 v.W food.y•i•d.r two a dealt or wo,racl letarast,n•SW*or Cc Cr 00 L•Ywor Or MOW Lrcanat7 If..legs-,ant**,,n 0•rs,1 <br /> .r•••••• r. - 4A <br />