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DEPARTMENT OF LIQUOR Cd&ROL <br />WV%_M <br />r�fflo <br />Lagoon Centre 101 Aupun� St.. Urnt 230 Hilo Nawoi i 96720 'Phone: (808J961-8218 `qx"Al961 _, <br />E-Mail' cohdlc Qhawailcounfvgov T1W <br />PERSONAL HISTORY AND AFFIDAVIT OCT 2 2025 <br />(Type or Print All Information) <br />Dept, of Liquor Control <br />NAME D°ice 1J'N6-E(Z MA �f�-1��...i ��-SAMI ks HILO <br />INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />ist registered business name and dba ti"00"i" 91SGua T- C0MQA Ny,(NG. KpN gISGuIT Co . <br />urrent office/title you hold with registered business OTF- kC _ Effective Date. o G 20 <br />(q. 25 <br />l ' <br />t applicable the percentage of stocks/shares you hood: <br />11. LIST PAST OWNERSHIP OF LIQUOR LICENSE - <br />LICENSEE NAME DBA ADDRESS <br />A � A ---v v�-- N <br />III EMPLOYMENT RECORD: (10-year �irstory bt?gtrnjng wrrh tone mos` recent emp/oyment) <br />FROM TO POSITION NAME OF COMPANY <br />->c97CLM E <br />/ m <br />If-dditional space is nceded, use reverse side <br />IV CRIMINAL RECORD.. IF ANY: Check box. <br />Wl Lip r� 6 00n VACATV)r�S . <br />have not been convicted of any felony Charges) <br />p i 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 />Subscribed <br />tn�sr-; - v of and sw?10% <br />orn to before me <br />da <br />.. . 20 <br />Notary ublr ` I - azure . <br />Notary ubli (print name` <br />STATE 0 <br />t j <br />My commission expires. <br />YEAR <br />N A- <br />CITY/STATE <br />WAlkotbA, H 1. <br />RuGKEI�- 1 CA—, <br />Signature of App ' nt before Notary <br />Doc. Date 4 Pa9 es - <br />Name' /gyl0; J-�0 it <br />C Duit <br />Doc Description- personal History Statement <br />4 <br />Notary SigrIoture Date <br />Revised: 08/2017 Hawai i Cou�yii 1B Upo4nity Provider and Employer <br />