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DEPARTMENT OF LIQUOR CONTROL <br />Hilo Lagoon Centre, 101 Aupuni St., unit 230, Hilo, Howari `i 96720 " Phone: (808) 961-821 "1645- <br />E-Mail: C ohdlo ��hawoiio©unfy. c <br />PERSONAL HISTORY AND AFFIDAVt' FS - 4 2019 <br />`Type or FWnt AN tnfor ior" <br />r� <br />�:v kjf iv�ti AS i�cEv�S7trttu iiii 6 n i iiE utF�lR i i�itf+iT OF �. GM, rit�2c: E �►tVJ %�3lvsL'Mck ArEAit�i. <br />List registered business name and dbo: Kukio Golf and Beach Club, Inc. <br />.urrent office/title you hold with registered business: Dredor <br />IS applicable, the percentage of stocks/shares you hold: NIA <br />r aro of i in, ir* Control <br />Effective Date: 1 11/19 <br />11 LIST PAST OWNERSHIP OF LIQUOR LICENSE- <br />' irm. Fr- N amf nRA AnnRFSS YEAR' <br />Ill. EMPLOYMENT RECORD: (10-year history beginning with the most recent employment) <br />FROM TO POSITION NAME OF COMPANY CITY/STATE <br />, f iditional soace is deeded. use reverse side. <br />!V. CRIMINAL RECOR0, IF ANY: Check box_ <br />.�; gave not been aorwtc ted of any €ekx iv c "ge i s) . <br />i� i hove 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 c ect. <br />s re of Apui�catWHIM 10110ary <br />Subscribed and sworn to before me <br />a <br />is 1_\rday of �,I fPoc. Date: # Pages: <br />2Q <br />Nor <br />• �O Circuit <br />0 <br />N to y Public (sI nature) NOTARY <br />Pt1a11C �cx:. flescription: P - r Or� 1 Hi - t � - 4t <br />Comm No.?0 pi 4V <br />12-377 <br />3tary f�• tic ;prn�ome) •' VOTMY •. <br />r % T= r-v c <br />•;OOCD <br />%%My commission expires:No ignoture <br />• <br />Revned: 08/2017 Hawai i County is an Equal Opportunity Provider and Empiofe; OF O <br />