Page 1 of 1 Form L-OIC (01/201) OWNERSHIP INFORMATION Continued for Prequalification Packet L-OIC (01/201) LOCATION INFORMATION 1. Trade Name of Location 2. Location Address City County State Zip Code OWNER INFORMATION 3. Type of Owner Individual Corporation City/County/University Partnership Limited Liability Company Other Limited Partnership Joint Venture Limited Liability Partnership Trust Last N ame First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Na me MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title Last Name First Name MI Title American LegalNet, Inc. www.FormsWorkFlow.com