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f <br />Y <br />DEPARTMENT OF LIQUOR C ROL <br />Ii <br />Hilo Lagoon Centre, 101 Aupunr St., Unit 230. Hilo Hawaii 96720 ' Phone: (808)961-8 x "9-a44 <br />E-Moil.' cohdlcshowancoun01) <br />t ov <br />PERSONAL HISTORY AND AFFIDAVIT C� "2 202' <br />(Type or Print All information) <br />Dept. of Liquor Control <br />1. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS - <br />List registered business name and dba je'u ra t u L ry c: 1..c�.r��. 9 + �C. ('t I --�' 6L) <br />#' � i � �� Current • f cell tle you hold with registered business: A��r� c N Effe.--tive Date 0 &4 [ t 12o2'S <br />if applicable the percentage of stocks/shares you hold <br />II. U51 PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA ADDRESS YEAR <br />tA �A <br />111. EMPLOYMENT RECORD: 10-year history beginning with the most recent ernployrnent <br />FROM TO POSITION NAME OF COMPANY CITY STATE <br />A.r <br />71-�k <br />. 1 <br />Ai r- - Af It C L C e. r <br />Q of <br />If addrtronal space 1s needed, use reverse side <br />IV CRIMINAL RECORD, IF ANY: Check box. <br />have not been convicted o` any felony charge fs) <br />have been convicted of a felony charge(s). if the answer is in tree aff rnnat,ve please lis: <br />being first duy sworn deposes and says that the Above information is true and Corre- f <br />Subscribed ands orn to before me <br />7 <br />} <br />this _ day of (= LC20 .� <br />Notes Public (signatur } <br />r <br />Notary Pub{ [ rint n me <br />STATE OF <br />My commission exp res. ..m ..�w....... <br />S, tu►e of Applicant before Notary <br />.01 <br />Doc. Date �#Pages <br />Name �l�r.�?��0 34oCircuit <br />Doc, Description: Personal History Statement <br />OtOS�ignature Date <br />Revised. 0812017 Hawa+ i Countesv nnart u ity Provider and Employer <br />CA <br />