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1) <br /> <br />~) <br /> <br />3) <br /> <br />4) <br /> <br />5) <br /> <br />6) <br /> <br />7) <br /> <br />~) <br /> <br />9) <br /> <br />1988 <br /> <br /> (Street, Box, Route) <br />Business Phone Number(s): .~.Z- ~ o 7 C/ <br /> <br />(City) (State) <br /> <br />(zzP) <br /> <br />Hours of Operation: <br /> <br />Applicant: L ~2,-~_."'7%? <br /> (Last Name) <br /> <br />(First l;ame) (Middle Initial) <br /> <br />Applicant's Address: ?~o~ ,Sc--,~,'5/ <br /> (Street, Box, Route) <br /> <br />(City) (State) (ZIP) <br /> <br />Applicant's Date of Birth: <br /> <br />Applicant's Position With Company: .~z'p ,/~ 5 , <br /> <br />If corporation, list below the names, residences and birthdates of those <br />owners holding more than 5% of the outstanding stock of the corporation: <br /> <br />i0) Manager: <br /> <br /> (Last 1;ame) <br /> <br />11) Manager's Date of Birth: <br /> <br />12) 14umber of Devices to be Used: <br /> <br />13) Types cf Devices to be Used: <br /> <br />(First Name) <br /> <br />(Middle initial) <br /> <br />14) Other cities or corn=unities where you've applied for cr held a license to <br /> operate a sir. il-r tvoe of busines¢: <br /> <br />15) Have you, er in the case cf a corpora:ion, the owners cf more than 5% of <br /> the outstanding stock of :he corpora:ion, been co~victed of a gross misde- <br /> meanor or felony relating to :he opera:ion cf ~usement cemters and related <br /> activities? _/~_ //"-, r~ yes, ezp!aim: <br /> <br /> <br />