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DEPARTMENT OF LIQUOR CONTROL COUNTY OF WAI'1 <br />Hilo Lagoon Centre, 101 A upuni St., Unit 230, Hilo, Hawaii 96720 ' Phone: (808)96 f -$Rf,q f (W j 0684 <br />E-mail: cohdlcQhawaiicountv.gov to <br />PERSONAL HISTORY AND AFFIDAVIT OCT 0 9 2025 <br />(Type or Print All IntormaMon) <br />Dept. of Liquor Caritrol <br />NAME: c G�SCPi? HILO <br />Last first Middle Maiden <br />1. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />List registered business name and dba: Hilo Yacht Club <br />Current office/title you hold with registered business, DirectorlTrustee Effect ve Date: 071:3112025 <br />If applicable, the percentage of siockslshores you hold: <br />11. UST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME WA ADDRESS iR <br />AM - <br />Ill. EMPLOYMENT RECORD: ( r0-year history beginning with the most recent employment) <br />FROM TO POSITIIONw NAME OF COMPANY CRY/STA/TE <br />T f �GJ"� /C °iJ� : /'1�� 4�•s�rl�%G LGl'sYYf f7 jtj�/yC.viW�t e l?�ilMN1/>Fi1I L - j/ 1, C 4. <br />if additional space is needed use reverse side <br />IV. CRIMINAL RECORD, IF ANY: Check box. <br />251 have not been convicted of any felony charge(s). <br />❑ I hove been convicted of a felony charge(s). If the answer is in the affirmative, please Est. <br />I being first duly sworn, deposes and says that the above information is true and correct. <br />\tltillllt/�j�� <br />M. Vr, , %�. Signature of Applicarlt before Notary <br />20 �SDoc Date. j' # Pages:L <br />.� Name: Damelia M. Villanueva Circuit <br />Doc. Description: Persona}tiistcr%tti�de� nt <br />Notary <br />rr % <br />STATE OF Public <br />NeL h Yt'I Ci r c Ut=i r <br />My commission expires: <br />Notary Signature ' Date <br />Revised: 08/2017 Hawaii County is an Equal Opportunity Provider a46p�►�y�t , <br />