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f <br />DEPARTMENT OF LIQUOR Cd&ROL jf <br />It <br />Hilo Cogoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawaii 96720 ' Phone. (808)961-8 <br />E-Mail: cohdlc@howoiicounty.gov <br />PERSONAL HISTORY AND AFFIDAVIT w <br />OCT � 2 2025 <br />(Type or Print All Information) <br />Dept. of Liquor Control <br />NAME DA VI�_ �31u./ R w�. _�uST/ Ai _ H I LO _^ <br />Last Middle Maiden <br />i. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />List registered business name and dba vv A +� K C.�t ( .- �J� ��� 1<d�►!� � St�-l. �-r . <br />w <br />Current office/title you hold with registered business. Q f IC- �. g _wv _ Effective Date. O�& 2o2S <br />'f applicable the percentage of stocks/shares you hold Z� <br />II LIST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA <br />ADDRESS <br />YEAR <br />III EMPLOYMENT RECORD: r 10-year history beginning with the most recent employment) <br />FROM TO POSITION NAME OF COMPANY CITY/STATE <br />S�� fit' <br />/ �� 7��5~ D�->1V�rrL.. T 1 Ti�� ` i��7i-�[..�s-�`Yd N s ! �. ,�t_o <br />If additional space is needed. use reverse side. <br />IV. CRIMINAL RECORD, IF ANY: Check box. <br />kri have not been convicted of any felony charge(s) <br />' ' have been convicted of o felony charge (s) . If the answer is in the affirmative please list. <br />'being first duly sworn deposes and says that the above informaf ..M n is true and correct <br />Subscribed andsMLA161&,n1 <br />0before me201..--.------..---- <br />thisq�olldray of <br />Not ub�(ic (sig turej <br />N tary Publi rint name) <br />STATE OF _ <br />My commission expires: <br />gnature of Applicant before Notary <br />Doc. Date. � 'S # Pages: <br />Name''dG1y�- - ;5�00rCuit <br />Doc Description: Personal History Stotement <br />a <br />Notary Signature Date <br />Revised: 08/2017 Hawail CounEi-^r��l ' pTorGity Provider and Employer <br />