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Get OH DLC4030 2013-2021

ONTROL http://www.com.ohio.gov/liqr OFFICER/ SHAREHOLDERS DISCLOSURE FORM (This form must accompany all applications of a corporate business entity) Name of Corporation DBA Name Permit Premises Address City, State Township, if in Unincorporated Area Tax Identification No. (TIN) Zip Code Email Address: SECTION B. 1. Is stock publicly traded? If "YES", YES NO YES NO indicate exchange ______________________________ & Do NOT complete SECTION D. 2. Does any stockholder own 5% or more .

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