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l <br />DEPARTMENT OF LIQUOR Cd&ROL WAIT <br />Hilo Lagoon �;entre. 101 Aupuni St. Unit 230 Hilo, Hawaii 96720 'Phone: (808)961-82���� �g�g <br />E-Marl: cohdic@hawalicounty.gov <br />PERSONAL HISTORY AND AFFIDAVIT d� <br />(Type or Print All Information) OCT � 2 2025 <br />NAME 10�(LJ15-_ TOIL .. IP <br />Dept. of Liquor Control <br />'fNc� r�F4 s F rl _Lo <br />I INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS. - <br />List registered business name and dbG- _ kONft (31SCUITT COMP A N J ItJ G . RlSc.�.0 Co <br />r'urrent office/title you hold with registered business: C (),VT I 2 Effective Date. 0 & �(�� 20 2S <br />'f applicable the percentage of stocks/shares you hold: _ �5 <br />LIST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA <br />NIP N)ik <br />ADDRESS YEAR <br />WK NIA <br />III EMPLOYMENT RECORD 10-year hlstory beginning with the most recent employment) <br />FROM TO POSITION NAME OF COMPANY <br />0V,3 esE2- / V 1 A v I A Ttor1 A ss eT <br />.62 D 2 E S EN 'r Co NrC e-P G''rD O F%A A N 41 G-e M e" T' (._,,L C . <br />(ju , g_. 3 2023 SR. Ass ET MAN A6;ep. AVIA-n0#4 CAPITAL. G2ou _ <br />5 1 201(o ?.a19 L o At-,] off Icy W ei is REs o wors <br />If additional space is needed use reverse side, <br />IV CRIMINAL RECORD. IF ANY: Check box. <br />have not been convicted of any felony charge(s) <br />have been convicted of a felony charae (s) . If the answer is in the affirmative please list. <br />CITY/STATE <br />'rp,U CA< VE r CA' <br />being first duly sworn, deposes and says that the above information is true and correct <br />S <br />Sign ture of Applicant before Notary <br />u scn 7 d <br />b and sworn to before me <br />this 4 <br />_ day o 20 <br />r <br />Notary Public (signature ) <br />Notary Pub i print name) _ <br />STATE OF �� (( _ <br />My commission expires:_ Lf- 'r_ <br />Revised. 08/2017 <br />Doc. Date, �6_ # Paged <br />r 1 <br />Name: Circuit <br />Doc. Description: Personal History Statement <br />Notary Signature <br />Hawai i Colet*BIPTPA rnty Provider and Employer <br />Date <br />CA . <br />