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SECTION 7 DISCLOSURE OF INTERESTED PARTIES" <br /> Note: Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of <br /> C t3 <br /> Our license. Cl <br /> Business Name (D/B/A) �- <br /> e. <br /> 1. When applicable, please complete the appropriate section below. Attach extra sheets if necessary. <br /> Title/Position Name Stock % 0- ,_ <br /> CORPORATION (CORP/INC) 'a <br /> President U., - <br /> Vice President _Y <br /> Secretary <br /> Treasurer <br /> Director(s) <br /> Stockholder(s) <br /> LIMITED LIABILITY COMPANY LLC/LC <br /> Managing Member(s) <br /> and/or Managers <br /> Members <br /> (must be printed if <br /> there are no <br /> managing members <br /> or mans ers <br /> LIMITED PARTNERSHIP (LTD/LP/LTDLLP) <br /> General Partner(s) <br /> Limited Partner(s) <br /> Bar Manager(Fraternal Organizations of National Scope only): <br /> DIRECT INTEREST <br /> Name of Individual or Entity (If a legal entity, list name under which the entity does business and its principles) <br /> Title/Position Name Stock% <br /> 2. Are there any persons not listed above who have guaranteed or co-signed a lease or loan, or any person <br /> or entity who has loaned money to the business that is not a traditional lending institution? <br /> ❑ Yes ❑ No <br /> If yes, and the terms create a direct interest in the business, you must list the person(s) or entity and <br /> indicate which of the below applies. Each directly interested person must submit fingerprints and a related <br /> party personal information sheet. Copies of a reements must be submitted with this application. <br /> Name Guarantor Co-signer Lender Interest Rate <br /> List <br /> Auth.61A-3.020&61A-5.0017,FAC 5 Eff. 7/30/12 <br />