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NS ONLY A change in the list must be filed by the applicant or permittee with the commission within ten (10) days of the date when the change became effective. Check one: Corporation Limited Liability Company Total shares authorized Partnership Limited Partnership Total shares issued Sole ownership Limited Liability Partnership Club Other legal entity Type: TITLE NAME AND HOME ADDRESS SHARES OR INTEREST HELD *SOC. SEC. NO. & DOB SSN DOB SSN DOB S.
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