APPCOR10191

• Permit No: C1980002
• IBM Index Class Name: Application Correspondence
• Doc Name: ATTACHMENT A AML CONTRACTOR OWNERSHIP AND CONTOL INFORMATION PACKAGE
• Media Type: D
• Archive: No

. If the contractor's legal structure is other than a sole
proprietorship, provide all the information set forth below
for every officer, general partner, shareholder (10$ or
greater voting stock), and director or any other person or
entity who owns or controls the applicant.
778.13 (c) (1) (2) (3)
I~I~,1 773.5
Name raffra3 e ri U _1 $ of Ownership ~
Mailing Address n ry u~g,3 ~ ].9. S.~tain St
City r,~,,.,;~„n State ~p Zip
Phon~g7n)~Li_7;g$t1e~tDate Position Assumed
SSN 77L_C,L_g7 R'2 EIN AL_11L'iSRI
Name CharmainP Clarke \~11 "' $ Of OWRershlp ~~
Mailing Address p_0_ Rnx 2q7 iig S. Main St
City (:,mn; snn State rn Zip ai 73n
Phon~g70)fi41_gq~le vv-p~a!4'%R~epate Position Assumed TigO
SSN 522-77-7100 EIN R4-11G15R1
Name
Mailing Address _
City
Phone Title
SSN
Name
Mailing Address
City State
Phone Title
SSN
Date
EIN
Name
Mailing Address
City State
Phone Title _
SSN
$ of Ownership
$ of Ownership
Zip
Date Position Assumed
EIN
Name
Mailing Address
City
Phone
SSN
_ Zip
Position Assumed
$ of Ownership
_ State Zip
Title Date Position Assumed
air
Name
$ of Ownership
Mailing Address
City State Zip
Phone Title Date Position Assumed
SSN EIN
$ of Ownership
State Zip
Date Position Assumed
EIN