Schedule Reg-1-A - Liquor Information Form Page 2

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Step 3: Identify your owners or officers
Part 1: Individuals - owner, officer, manager, director
Part 2: Businesses
a
___________________________________ _________________
a
_________________________________
____-____________
Legal name
Title
Legal name
FEIN
______________________________________________________
Home address - No PO Box number
City
State
ZIP
______________________________________________________
Legal address
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
(______) ______ - ________
______
Ownership percentage:
_______ - _____ - _________
______
Ownership percentage:
Phone
Social Security number
b
b
___________________________________ _________________
_________________________________
____-____________
Legal name
Title
Legal name
FEIN
______________________________________________________
Home address - No PO Box number
City
State
ZIP
______________________________________________________
Legal address
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
(______) ______ - ________
______
Ownership percentage:
_______ - _____ - _________
______
Ownership percentage:
Phone
Social Security number
c
c
_________________________________
____-____________
___________________________________ _________________
Legal name
Title
Legal name
FEIN
______________________________________________________
Home address - No PO Box number
City
State
ZIP
______________________________________________________
Legal address
City
State
ZIP
____ / ____ / ________
(______) ______ - ________
Date of birth
Phone
(______) ______ - ________
______
Ownership percentage:
_______ - _____ - _________
______
Ownership percentage:
Phone
Social Security number
Part 3: Corporate stockholders owning more than 5%
d
___________________________________ _________________
Legal name
Title
a
___________________________________ _________________
______________________________________________________
Legal name
Title
Home address - No PO Box number
City
State
ZIP
______________________________________________________
____ / ____ / ________
(______) ______ - ________
Home address - No PO Box number
City
State
ZIP
Date of birth
Phone
____ / ____ / ________
(______) ______ - ________
_______ - _____ - _________
______
Ownership percentage:
Date of birth
Phone
Social Security number
_______ - _____ - _________
______
Ownership percentage:
Social Security number
e
___________________________________ _________________
Legal name
Title
______________________________________________________
b
___________________________________ _________________
Home address - No PO Box number
City
State
ZIP
Legal name
Title
____ / ____ / ________
(______) ______ - ________
______________________________________________________
Date of birth
Phone
Home address - No PO Box number
City
State
ZIP
_______ - _____ - _________
______
Ownership percentage:
____ / ____ / ________
(______) ______ - ________
Social Security number
Date of birth
Phone
_______ - _____ - _________
______
Ownership percentage:
f
___________________________________ _________________
Social Security number
Legal name
Title
______________________________________________________
c
___________________________________ _________________
Home address - No PO Box number
City
State
ZIP
Legal name
Title
____ / ____ / ________
(______) ______ - ________
______________________________________________________
Date of birth
Phone
Home address - No PO Box number
City
State
ZIP
_______ - _____ - _________
______
Ownership percentage:
____ / ____ / ________
(______) ______ - ________
Social Security number
Date of birth
Phone
_______ - _____ - _________
______
Ownership percentage:
Social Security number
*094302110*
REG-1-A (N-04/10)
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