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DEPARTMENT OF LIQUOR Cd&ROL � WAIT <br />Hilo Lagoon Centre. 101 Avpuni St., Unit 230 Nilo, Hawai'i 96720 'Phone: (808)961-82� ��f �g D8 <br />E-Mail: cohdlc 4 hawaiicounfv pov <br />PERSONAL HISTORY AND AFFIDAVIT a� <br />(Type or Print All Information) OCT 2 2025 <br />NAME �O�{� �I►JGEQ �µll�P <br />Dept. of Liquor Control <br />"fN c� r�� s Ffi LO <br />I. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS <br />List registered business name and dba koNik (; i sCE tr co MP A N 1 -1 IN G . IN9A : p� ,�P 15� r CO <br />Current office/title you hold with registered business: ` �� <br />,,.. � ��� Effective (v[L--4� ° 2ET 2 1 +� � E ect,ve Date o2 S <br />If applicable. the percentage of stocks/shares you hold: <br />N LIST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA <br />NIA N)ft <br />ADDRESS YEAR <br />N I h N la <br />III EMPLOYMENT RECORD: 10-year history, beginning w th tr ? most recent employment) <br />FROM <br />TO POSITION <br />NAME OF COMPANY <br />CITY STATE <br />2 <br />0 atSVCz.- / <br />Ga Nrr e f%M a <br />V 1 Av I A-norJ AsseT- <br />AAA N A G-eM eNr L-1-c - <br />C AN W <br />`Z t <br />3 20 2 3 sR . AssET MA N A 6eoz <br />A\Omoti CAPITAL- 6gou _ <br />N� w Po2��Bt a C}I � CA . <br />5 U1 (0 <br />LAR %J OTI-- I AER <br />W e-LK RFso all -s <br />--(Qu WE)E CA - <br />if additional space rs needed, use reverse side. <br />IV CRIMINAL RECORD, IF ANY: Check box. <br />hove not been convicted of any felony charge(s) <br />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 that the above information is true and correct <br />. v <br />Sign ture of Applicant before Notary <br />wubscri d and sworn to before me <br />C, <br />this f� <br />470'�jday o <br />r <br />Notary Public (sjgnature i <br />Notary PubJic 1print name <br />STATE OF U� lrc <br />My commission expires: - <br />>G <br />Doc. Date _ _ #Pages <br />Name ��%} Circuit <br />Doc Description: Personal History Statement <br />Notary Signature <br />Revised. 08/2017 Hawa+ i CoLEX l fpof1n,ty Provider and Employer <br />A), -2 zo, <br />Date <br />