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DEPARTMENT OF LIQUOR CONTROL CODUIC Q�6�LJ <br />Hilo Lagoon Centre, 101 Aupuni St. Unit 230, Hilo. Howai i 96720' Phone (608)961-8218 ' Fi <br />E-Moil: Cohdlcahowaiicounty.00v <br />PERSONAL HISTORY AND AFFIDAVIT AUG 2 6 2025 �- <br />(Type or Print All Information) <br />Dept. of Liquor Control <br />NAME CkArtnb11`1 , `"TdSrnine L4 Or-4-It H ILO <br />Please submit copy <br />1. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS. <br />List registered business name and dbo 1310cit Orly X 1Er?Itr+Qjrw *e-t+ / <br />Current office/title you hold with registered business- &brvqer Effective Date V Z9. 2`f <br />If applicable. the percentage of stocks/shares you hold tj fry <br />11 LIST PAST OWNERSHIP OF LIQUOR LICENSE <br />LICENSEE NAME DBA DA DRESS YEAR <br />_ t4 t _ ..___ _. - — — — — <br />111. EMPLOYMENT RECORD: 10 year h st ry beginning with 'ne most recent employment! <br />FROM TO POSITION NAME OF COMPANY CITY/STATE <br />8 ' 9. 1 ! P resen+ Prrr"i i7o l 4re"4h 't <br />AH,g( <br />if additional space is needed use reverse side �Q�. ............hqy <br />NOTARY ' Gw <br />+IV,,,CRIMINAL RECORD IF ANY: Check box <br />u ; PUBLIC <br />Tyave not been convicted of any felony charge s) <br />: * ` No. 23-320 <br />�y : (•• d�pve been convicted of a felony charges if the answer is m tre affirmative please list ;r <br />PUBLIC 'i� - OF NP��\�`. <br />* No. 23-320":1*1 G'st duty sworn deposes and says that the above informatior is true and Corr ++++,+,+,+l'`�,, <br />OF NP S nature o Appl ant before Notary <br />'Sviiscribed and sworn to before me <br />this 2w, of 1 c ��A_ 20 � Doc. Date L� ZpLS a Pages- <br />torybrit (si <br />NameCU amoh,1101hgnv1lu� Circuit <br />No•gnature) <br />ctw AulII0Ii -- - <br />Notary Puq is (print name) <br />STATE OF _i4AWal t <br />My commission expires: wry%_ w( <br />Doc Description Personal HiOM Statemgnl__„___ <br />Nota S�gnotvrF <br />61pt5 <br />Date <br />Revised 08/2017 <br />Hawai i County is an Equal Opportunity Provider and Employer <br />EXHIBIT 1 <br />