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DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAI'I <br />Hilo Lagoon Centre. 101 Aupun M, Hilo. Hawaii 96720' Phone: (808196 t-8218 ''R CU ME D <br />E-Mail:Cohdlcshowaiicounty.00v 1`L_ CI v <br />PERSONAL HISTORY AND AFFIDAVIT <br />(Type or Print All Information) MAY 16 2025 <br />NAME He. XivAlov) cj Dept. of Liquor Control <br />1. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF CO MERCE AND CONSUMER AFFAIRS: <br />List registered business name and dbo:_S(2rAb1 (S k'% CVe F_1_ «-L _ <br />Current office/title you Fold with registered business: _ _�rv� y _ Effective Date: <br />If applicable. the percentage of stocks/shores you hold: _. _ <br />It LIST PAST OWNERSHIP OF LIQUOR LICENSE <br />LICENSEE NAME DB ADDRESS YEAR <br />a YA 50S�L _ 7/4m -75-53o3 4(i i 1k. g5 Ww� i k-jyA <br />III EMPLOYMENT RECORD. i 10-year history beginning with the most recent employment) ' FROM 4 POSMON N F COMPArCITY/STATE <br />Zp2�\ NOL✓ l�er H XU1lL/A �39�i <br />i 022 o-i-4 0-jaOr rh}l/kh 5U501 1(a4uw k5v1 <br />2'01'4 '10-1 NuAer SurYlo ( ka, lNc. !Coro <br />If adddralW space is needed, use reverse side <br />IV. CRIMINAL RECORD, IF ANY: Check box. <br />*: P9 19 <br />•• No. 99.524 <br />not been convicted of any felony Chargels) <br />been convicted of a felony (;ttoPdMli'."d&e answer is in the affirmativeplease list. <br />Iau�r sworndeposes ov 57 <br />iatiwom to before me 9 <br />• <br />,of Oj+p�' .20a-�^S. <br />Notary Public fsignature) <br />T <br />"s th(E abo0�fprmation is true and correct. t <br />PVBL/RCY :vC c <br />No•• , 99 52 t Signat of Applicant before Notary <br />Ole. <br />F • q �APd4k',,/"�y-.=" _ a Pages:j— <br />'�r44un,PrN�d <br />Name _�. IQJ�JQ_- lnrroClfcUlt <br />Doc. Description: Personal History Statement <br />Notary Pu lic (print name) <br />STATE OF ii ctni1111,11 A 11 � �/�I/I "// `�,_� <br />Mycommissione.pir s: f__—S1d�tl�.-V1_S✓V1yi�ePW- io / <br />Notary Signature Date <br />Rev,,•d'PFRESA A. KUALAAU Hawaii County is an Equal Opportunity Provider and Employer <br />Notary Public, Third Judicial Circuit <br />-- - Stale el l4awaii - -----EXHIBIT 1- --- <br />