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SECTION 7 — DISCLOSURE'OFI INTERESTED PARTIES. <br />Note Failure to disclose an interest, direct or indirect, could result in denial, suspension and/or revocation of <br />your license <br />Business Name (D/B/A) <br />1. When applicable, please complete the appropriate section below Attach extra sheets if necessary <br />Title/Position <br />Name <br />Stock % <br />CORPORATION (CORP/INC) <br />President <br />Vice President <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 managers) <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 <br />Name <br />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 agreements must be submitted with this application <br />Name <br />Guarantor <br />Co-signer <br />Lender <br />Interest Rate <br />(List) <br />[- <br />n <br />❑ <br />n <br />- <br />❑ <br />❑ <br />❑ <br />n <br />Auth. 61A-3.020 & 61A-5.0017, FAC <br />5 <br />Eff. 7/30/12 <br />