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Are each ofth, e of~cers and/or shareholders citizens of the United States? <br />Yes,.~ . No <br />tf naturalized, state date and place of naturalization <br /> <br />ITfno, state the circumstances for each partner who is not a c/.tizen. /¢/,~ <br /> <br />4. Give the full name and address of each officer's/shareholder's spouse. <br /> <br /> Officer/Shareholder Spouse <br /> <br />' ~ ~ / <br /> <br />Address <br /> <br />Has any one of the officers/shareholders ever used or been known by a name other than <br />his/her true name.'? Yes No <br />If yes, state what was such name or names, and information concerning dates and places <br />where used: <br /> <br />List occupations each partner has followed for the past five years? <br /> <br /> Officer Occupation <br /> <br />Officer Occupation <br />0 ffic~r Occupation <br />Offer b~c~p'ation ' <br /> <br />Has any one of the officers/shareholders ever~been in the military service? <br />Yes No ,~. <br />7If yes, state which officer/shareholder(s) <br /> <br />State trade name to be used for the licensed premises:--~WC'/~ <br /> <br /> I <br /> I <br /> I <br /> I <br /> I <br />.I <br />I <br /> <br />I <br /> <br />-230- <br /> <br />Page 2 of 6 <br /> <br />I <br />I <br /> <br /> <br />