In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the licensee. Attach additional sheets if necessary. A. Individual and/or Entity Ownership of Licensee (Excludes Voluntary Board Members) % EIN FULL NAME of INDIVIDUAL or PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER OWNERSHIP (No SSNs) ENTITY INTEREST B. Board Members and Officers of Licensee TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER Director/CEO President Vice President Secretary Treasurer Other: 4. Management Company Controlling Interests Does a company other than the licensee manage the licensed provider? If NO, skip to section 5 Required Disclosure. – If YES, provide the following information: Name of Management Company EIN (No SSN) Telephone Number / Fax Street Address E-mail Address City County State Zip Mailing Address or Same as above City State Zip Contact Person Contact E-mail Contact Telephone Number In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary. A. Individual and/or Entity Ownership of Management Company % FULL NAME of EIN PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER OWNERSHIP INDIVIDUAL or ENTITY (No SSNs) INTEREST
In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the licensee. Attach additional sheets if necessary. A. Individual and/or Entity Ownership of Licensee (Excludes Voluntary Board Members) FULL NAME of INDIVIDUAL or ENTITY PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER EIN (No SSNs) % OWNERSHIP INTEREST B. Board Members and Officers of Licensee TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER Director/CEO President Vice President Secretary Treasurer Other: 4. Management Company Controlling Interests Does a company other than the licensee manage the licensed provider? If NO, skip to section 5 – Required Disclosure. If YES, provide the following information: Name of Management Company EIN (No SSN) Telephone Number / Fax Street Address E-mail Address City County State Zip Mailing Address or Same as above City State Zip Contact Person Contact E-mail Contact Telephone Number In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary. A. Individual and/or Entity Ownership of Management Company FULL NAME of INDIVIDUAL or ENTITY PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER EIN (No SSNs) % OWNERSHIP INTEREST
Application_TLF_Revised_8_6_15.docx