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DEPARTMENT OF LIQUOR C*ROL M T <br />Hilo Lagoon Centre. 101 Aupunr St .Unit 230 Hilo. Hawa��t 96720 'Phone: (808)961-84��:k���'dL8684 <br />E-mail: cohdlc@hawoHcovnfv.aov <br />NAME <br />PERSONAL HISTORY AND AFFIDAVIT 9 w <br />(Type or Print All Information) OCT - 2 2025 <br />_ ZA-V I S l.� tc..�.� A+ti.- Aja sT1 ill <br />Lost First Middle <br />Dept. of Liquor Control <br />HILO <br />Maiden <br />I. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />'List registered business name and dba _1<0+tiR 19!S CA4 f -C (kA PA_-W 1 I N�� �F3P� xowA &<cA-LvT Co. <br />Current office/title you hold with registered business. Q�'�2 _eM Effective Date. of 2D2S <br />If applicable the percentage of stocks/shares you hold- 7,-> <br />II, LIST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME DBA <br />ADDRESS <br />YEAR <br />III. EMPLOYMENT RECORD: (10-year history beg, n ng with the most recent employment) <br />FROM TO POSITION NAME OF COMPANY CITY STATE <br />qT.�v� <br />T T l _N���t.t�l�-tl N S l,� �tao 2� oA <br />If additional space is needed use reverse side. <br />IV CRIMINAL RECORD IF ANY: Check box. <br />have not been convicted of any felony charges, <br />have been convicted of a felony charge(s). if the answer is in the affirmative please list. <br />bF,ng first duly sworn deposes and says that the above information is true and correct <br />Subscnbed and s Orn to before me <br />l/�fir- � / <br />th�sday of ����-�' 20 1 <br />Not r7$Pub-lic (sig Lure) <br />N tary Publi - rint n � e) <br />STATE OF A"f <br />My commission expires.=2� <br />gnature of Applicant before Notary <br />0 .v--- <br />Doc. Date. # Pages. <br />Name Circuit <br />Doc Description- Personal History Statement <br />Revised: 08/2017 Hawail Coun EsXI-1111- or sty Provider and Employer <br />