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r <br />A <br />DEPARTMENT OF LIQUOR Cd&ROL <br />ffilo Lagoon Centre 10 1 Av uni St. Unit 230 i <br />p , H lo. Hawaii 96720 `Phone: (808)961-82 1P Pow 9 I - <br />E-Mail: cohdlc a�howohcovnty qov <br />NAME wD 0 1 LC 'b I N &IFR <br />PERSONAL HISTORY AND AFFIDAVIT OCT ` 2 2023 <br />(Type or Print All Information) <br />Dept, of Liquor Control <br />'GCt4 -SAM o4s Hj-LO <br />i. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />1st registered business name and dba 1<'DtJft Q 1SCW T- C� NIQ� N y ! IN G- . 'D6A - KO PJ g ISCUIT Co . <br />urrent office/title you hold with registered business- DT� 1CM Effective Date. 0 6 jj%/W225 <br />f applicable the percentage of stocks/shares you h�, <br />II. UST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA ADDRESS YEAR <br />0A N�A NIA N �A- <br />III EMPLOYMENT RECORD: 10-year history beginnina w;th the most recent employment) <br />FROM TO POSITION NAME OF COMPANY <br />97# ��1�% ' L. VGar+ 0b VACAT7DW <br />2ou sates <br />If ac dit nal space is needed use reverse side <br />IV CRIMINAL RECORD, IF ANY: Check box. <br />CITY/STATE <br />WA t 1<01.O A, H I. <br />5xEruT1\J� We-Lj< 4?ES0R21-K -QuGK <br />have not been convicted of any felony � harge(s) <br />I have been convicted of a felony charge (s) . If the answer is in the affirmative please list <br />being first duly sworn, deposes and says tha' the above information is true and correct <br />Subscnb7V and sworn to before me <br />elelk <br />tnis day of L <br />_. ..r y ._ . zz <br />Notary �bli i ature) <br />^rotary ubli (print nome) <br />STATE OF <br />My commission expires: r_u <br />Revised- 08/2017 <br />Signature of App <br />'Jieghit before Notary �F <br />Doc. Dafe 2� q Poges � <br />Name:�\�%��� Wye-' �go Circuit <br />Doc. Description- Persona! HistoryStatement <br />Notary Signature Date <br />Hawat i Cou j UpAnity Provider and Employer <br />to er <br />F <br />