Address Line 3: City: State: Zip Code: Phone: Fax: Email: Stock type or class: Number of shares held: Date Acquired: Percentage of outstanding voting stock: conditions, rights and privileges: Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of birth: Address Line 1: Address Line 2: Address Line 3: City: State: Zip Code: Fax: Email: Stock type or class: Number of shares held: Date Acquired: Percentage of outstanding voting stock: Terms, conditions, rights and privileges: Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of birth: Address Line 1: Address Line 2: Address Line 3: City: State: Zip Code: Fax: Stock type or class: Number of shares held: Date Acquired: Percentage of outstanding voting stock: conditions, rights and privileges: Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of birth: Address Line 1: Address Line 2: Address Line 3: City: Zip Code: Phone: Fax: type or class: Number of shares held: Date Acquired: Percentage of outstanding voting stock: conditions, rights and privileges: If more space is required, please submit additional information on other owners of the corporation in a separate document titled “Owners of the Corporations (Contd.)” in accordance with the attachment file name format requirements and include it with the attachments. For partnerships and LLPs Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of birth:
Address Line 1: Address Line 2: Address Line 3: City: Zip Code: Phone: Fax: Email: Partner Type: General/Full Partner Limited Partner Dormant/Silent Partner Other: Percentage of ownership: Partnership participation from: Description of participation in operation of the applicant: Name and Residential Address Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of birth: Address Line 1: Address Line 2: Address Line 3: City: State: Zip Code: Phone: Fax: Partner Type: General/Full Partner Limited Partner Dormant/Silent Partner Percentage of ownership: Partnership participation from: Description of participation in operation of the applicant: Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: in the applicant’s business: Also known as: Date of birth: Address Line 1: Address Line 2: Address Line 3: City: State: Zip Code: Fax: Email: Partner Type: General/Full Partner Limited Partner Dormant/Silent Partner Percentage of ownership: Partnership participation from: Description of participation in operation of the applicant: Name and Residential Address First Name: Middle Name: Last Name: Suffix: Occupation: Title in the applicant’s business: Also known as: Date of Address Line 1: Address Line 2: Address Line 3: City: State: Zip Code: Phone: Fax: Email: Partner Type: General/Full Partner Limited Partner Percentage of ownership: Partnership participation from: Description of participation in operation of the applicant: