Disclosure Of Interested Parties

DISCLOSURE OF INTERESTED PARTIES PERMIT NUMBER: Pursuant to I.C. 7.1-3-21-8, list any and all persons who are directly or indirectly, financially or beneficially interested in this permit. 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. CORPORATIONS ONLY Check one: Total shares authorized Corporation Limited Liability Company Sole ownership Partnership Club Limited Partnership Total shares issued Limited Liability Partnership Other legal entity Type: SHARES OR INTEREST HELD TITLE NAME AND HOME ADDRESS *SOC. SEC. NO. & DOB % SSN DOB SSN DOB SSN DOB SSN DOB SSN DOB SSN DOB SSN DOB SSN DOB SSN DOB AFFIRMATION OF APPLICANT Name of applicant (individual, corporation, partnership, LLC, LLP) I certify that this application was completed by myself or by the preparer identified herein. I certify that all information provided herein and on any attachments are true and correct. UNDERSTAND THAT IT IS A FELONY TO MISREPRESENT OR FALSIFY ANY PORTION OF THIS APPLICATION OR ATTACHED DOCUMENTS. I I hereby consent for the duration of the permit term to inspection and search by an enforcement officer, without a warrant or other process, of my licensed premise and vehicles to determine compliance with the provisions of I.C. 7.1. Printed name and title of applicant Signature Date NOTE: The applicant MUST sign this application unless the proper Power of Attorney forms are attached to this application. SIGNATURE OF PREPARER (IF APPLICABLE) I certify that I have examined this application and the accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete. Signature of preparer Telephone Number Date American LegalNet, Inc. www.FormsWorkFlow.com