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DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAII <br />Hilo lagoon Centre, 101 Aup uni St., Unit 230, Hilo, Hawaii 96720 ' Phone: (808 j961-8218 ' Fax: (808) 96 t -8684 <br />. <br />E-Advil: cohdic.@howailcoun.ty.gov - �, <br />PERSONAL HISTORY AND AFFIDAVIT <br />(Type or Print AN In#otmcdion) <br />�w <br />MAY 13 2026 <br />NAME �l���'�--.___.._----- DeLt, ofti_Quor tontroI <br />I. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS: <br />d OVA ea"'V'v L( kk(16,vj4 C0''Vda e��c.�!_ist registered business Warne and dbt�.!�&Current office/title ou hold with re istered business. �..1' /Ujv'kr' Effective Date <br />if applicable, the percentage of stocks/shares you hold-. <br />It. LIST PAST OWNERSHIP OF LIQUOR LICENSE: <br />LICENSEE NAME ADDRESS YEAR <br />LA—�- J t V' # �J ►�- L�.- �' �; IL3 • y 1 t j� u► <br />III. EMPLOYMENT RECORD: (10-year history beginning with the most recent employment) <br />fROM TO POSIT NAME Of COMPANY Cl STATE <br />A4C4704af dX.-P OJ_ u4-44 <br />!f additional space is needed, use reverse side. a •���`A'M'+�•�,,: <br />IV. CRIMINAL RECORD, IF ANY: Check box. �.•` �' 0 T A'*��,���'�. <br />*of have not been convicted of any felony charge (s). = • <br />have been convicted of a felony charge(s). If the answer is in the affirrmotive, please list. <br />i � r <br />• <br />,I� •8 L <br />•.•••• <br />t being first duly swan. deposes and says that the above information is true and correc w r <br />/Iff11t11��� <br />Signature of Applicant before Notary <br />Subscribed and sworn to before me <br />i <br />is do of . 20 aoc. Bate: # Pages:AM ` <br />Name: .. Circuit <br />Mcytary ru Isrgrtazurel <br />j Doc. Description: Personal History Statement <br />VA V <br />Notary Publ' 4 rint nome) <br />STATE OFAAtow <br />tv► commissionexpires: Y/ <br />y C s�. <br />No ry Signal to <br />Revised: OBY2017 Hawaii County is an Equal Oppc u ity Provider and EMptayer <br />