Form Dlc4031 Ohio Department Of Commerce Division Of Liquor Control - Partnership Disclosure Form Page 2

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Page 2
DLC4031 (PARTNERSHIP DISCLOSURE FORM)
SECTION C.
(CONTINUED)
ALL GENERAL PARTNERS LISTED BELOW MUST HAVE A BACKGROUND CHECK PERFORMED BY BCI&I AND SUBMIT A PERSONAL HISTORY
BACKGROUND FORM. PLEASE READ "BACKGROUND CHECK INFORMATION" DLC4191.
Social Security No. (If Individual)
3)
Individual Name
Residence Address
Tax Identification No. (If Applicable)
City and State
Telephone No.
Date of Birth
Zip Code
4) Individual Name
Social Security No. (If Individual)
Residence Address
Tax Identification No. (If Applicable)
Telephone No.
City and State
Date of Birth
Zip Code
5) Individual Name
Social Security No. (If Individual)
Residence Address
Tax Identification No. (If Applicable)
City and State
Telephone No.
Zip Code
Date of Birth
Social Security No. (if Individual)
6) Individual Name
Residence Address
Tax Identification No. (if Applicable)
Telephone No.
City and State
Zip Code
Date of Birth
7) Individual Name
Social Security No. (If Individual)
Residence Address
Tax Identification No. (If Applicable)
Telephone No.
City and State
Date of Birth
Zip Code
8) Individual Name
Social Security No. (If Individual)
Residence Address
Tax Identification No. (If Applicable)
Telephone No.
City and State
Date of Birth
Zip Code
9) Individual Name
Social Security No. (If Individual)
Residence Address
Tax Identification No. (If Applicable)
City and State
Telephone No.
Date of Birth
Zip Code
Social Security No. (If Individual)
10) Individual Name
Residence Address
Tax Identification No. (IfApplicable)
City and State
Telephone No.
Date of Birth
Zip Code

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