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e. OTHER ENTITY: the officers, the members of the governing body, and each <br />person having an interest of more than 10% <br />Name & Address <br />Title and nature and percent of interest <br />6. Names, addresses, and the nature and percent of interest of each person or entity (not <br />named in Item 5) who has a beneficial interest in any of the shareholders or investors <br />named in Item 5 which gives such person or entity more than a computed 10% interest in <br />the Applicant (for example, more than 20% of the stock in a corporation which holds 50% <br />of the stock of the Applicant; or more than 50% of the stock in a corporation which holds <br />20% of the stock of the Applicant). <br />Name & Address <br />Title and nature and percent of interest <br />7. Names of officers and directors, or trustees of any corporation or firm listed under Item 5 <br />or Item 6 above. <br />Name & Address <br />Certification <br />Title and nature and percent of interest <br />I (We), Certify that this Statement for Public <br />Disclosure is true and correct to the best of my (our) knowledge and belief. <br />Name <br />Signature <br />Title <br />Date <br />Name <br />Signature <br />Title <br />Date <br />(/f the Applicant is an individual, this statement should be signed by such individual; if a partnership, it should be signed by one <br />of the partners; if a corporation or other entity, it should be signed by one of its chief officers having knowledge of the facts <br />required by this statement.) <br />L <br />