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INSTRUCTIONS <br /> 1)Check the appropriate box for the type of licsnseiti being applied for on page 1. 11 you are applying for a <br /> retail license described in Column A. contact the Local Licensing Authority to obtain all local procedures <br /> and rtlquirementa. <br /> 2)You may attach tapers*thefts or additional documents if necessity to fully complete this application. <br /> Copies may be accepted (other then application) if signature%are evident All documents mutt be WI* <br /> written or legibly primed in BLACK ink. <br /> 3f IMP9RTPST: For those retail licenses described in Column A on page 1,Mk application and all auppa't• <br /> ing docurnenb must MIT <br /> AUTHORITY.Applketion will not be accepted tinkles ell appticsbte shares ars hilly I sup. <br /> ponting4o uments correspond aacaedy with the name of the pikan s) and proper Noe ere act <br /> 4)Form DRL 404-I, "Individual History Record"mutt be oompieied and filed in dupe cess by the following: <br /> e. Each applicant <br /> b.All wend partnere • <br /> c. Over 5%united partners <br /> d.All officers and directors of a corporation <br /> a. AU stockholders of a corporation not subject to the Securities and Exchange Act of 1934. <br /> f. Over 5%stockhoiders of a corporation subject to the Securities and Exchange Act of 1934. <br /> V. Omitting~eon <br /> h.Each person required to file form DR L 401-I must submit fingerprints to Local Licensing Authority. <br /> 5)NOTE:License statue will not be given over the Wepiwne. Liam will be moiled to the Leal Licensing <br /> Authority upon ilisiartir. <br /> OATH Of APPLICANT <br /> This appllk don is to be*mod by indMidual,seek gareeral peruser of partnership and Isyy eapolia l aiplMates, <br /> I cholera under morality of- in to eaters ism Sat 1 Mica reset tics fwegairg stmliamitat and di otomat sarrle awar+rssr <br /> and that 1 know tM argrto trnrsef,and that SI r s and inf nnodsrr lot Mr*iirein era sae,soma and aas*lasi a <br /> the boot of soy tewwrlerps ace f irrfserweiie . arid I aerie Is caRkw* r• M aeriiceiis soewer and Arnim*awl raIPIlesiem <br /> ProatuMHad by the Wads Daperanerra Tion a s ire.srswesiin <br /> INDIVIDUALS AND ALL GENERAL PARTMERS OF CORPORATIONS SIGN I RE: <br /> PA filtOISION MERE . <br /> } <br /> DATE: O Yew ar <br /> DATA:, <br /> REf'OAT Qf LOCAL MINIM AUTHORITY <br /> coos J/ACTHIIIPIL INP+aetTIONILS OUNALrla O0e01111nolD INN aelCflOaq <br /> The foregoing ap#icsdar* hse bore amtseat1 awl Ito l+arrrioiw.estrous eeardgsad and etnraaesr of as areliaine ie eaels <br /> facwry.We do report the oil liurafL Rccerel arMl• of 0*reap.rablN tottSPOISOnS of sire Meese and tree declass <br /> of the inhabitants. and of tiod a with 0* ErerNlswa rf TIde 12, Ankh. 47. OW UM as assoniaL 111EREfORE TNIS <br /> APPLICATION 10 HIRISY APPROVID. <br /> CAMS AT. Mb rat►st. .AO,ttl..- <br /> AT <br /> Wass of awl - Berl •..�� <br /> ov: <br /> • e t Owl of easier rwraeiewm Or gMar mere M ere r-- s i <br /> AT1 U?: <br /> Mar__ abler woo - end se Inverses <br /> lit the prawrieee are locarrf NM*s Noe or day.ere Moo aape►rrd dnmaid its demi by the now and dark.if In s surge, <br /> item by the chairmen of the Mrd of aftwi y ansain amort and tv 1st is the ewe.H.br srdirianw or oeleerrrirs,sure howl <br /> Booing authority is sonar awe aAhid,eras sob ammo'tinned be 10+10 IN sera ef0aid4 <br /> Load Lioetnirt,AriStarily roan Os Mooting poreeittittg is midi WINO 10 Ica lamer DILL 4044: <br /> PING& iMTED a ITTEO IACf(0 Yet GM A C.$$..G CHICKS <br /> Vag P 4 e14 <br />