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DEPARTMENT OF LIQUOR C(*ROL 10 III <br />Hilo Lagoon Centre )O! Aupuni Si., Unit 230, Hilo. Hawol'i 96720 'Phone: (808)96 f-8R9�x. b8 9 -BS�34 <br />E-Mail: cohdlc showpilcounty_pov <br />PERSONAL HISTORY AND AFFIDAVIT S U I -- 2. 2 G2Dr <br />(Type or Print All Information) <br />w.+ Dept. of Liquor Control <br />mo <br />I. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />L <br />List registered business name and dbca 1Lv Y�ft, ��.. L �: ♦ ' ts -t t,) <br />c.. <br />Current office/title you hold with registered business. Effective Date 0 0 [% 12o2`5 <br />If a lip_: able the percentage- ` <br />pp p g� of stocks/shares you hold Z�` <br />II LIST PAST OWNERSHIP Of LIQUOR LICENSE <br />LICENSEE NAME DBA ADDRESS YEAR <br />r� �A r, � P4 N �-Pr 0 _� <br />III EMPLOYMENT RECORD: l 10-year hrsfoy beg'nn ng with the most recent employment' <br />FROM TO POSITION NAME OF COMPANY CITY/STATE <br />14 T r <br />—6'/L'r L S M(Ay'i,)) ZC, 4 r11 r'�L _ .�" � � , < < C 13 e ' _ZL f.:::l wc/ <br />If additional space is needed. use reverse side. <br />IV CRIMINAL RECORD, IF ANY: Check box. <br />�(I have not been-nvicted of any felony charge f s) <br />( I have been convicted of a felony charge(s). If the onswer is in the affirmative please list <br />I bung first duly sworn deposes and says that the above information is true anti correct <br />Subscribed and s orn to before me <br />this G day of7 �C u- �r 20 <br />Nato Public (signatur ) <br />Notary Pubii ( not n me <br />STATEt <br />OF <br />My commission expires: �- <br />S' lure of Applicant before Notary <br />Doc. Date # Pages <br />age .� <br />3o <br />Name: 14Circuit <br />Doc. Description: Personal History Statement <br />Aar nature Date <br />Revised: 08/2017 Hawai i Coun u try Provider and Employer <br />MA 113 <br />