Modification Form 27 – Business and Ownership Summary Report (11-7-2022) Analyst Review:
☐ Recommend Approval
☐ Other:
_______________________________________
Signature
Secondary Review:
☐ Approve
☐ Other:
__________________________________________
Signature D
ate
Entity Owners
License Number: Activity:
Legal Business Name:
Conflicting Owners Yes ☐ No
Owners SOS Verified:Previously Identified SOS Owners
Additional Owners IdentifiedAdditional Owners Identified Entity Owners
Summary Report of Changes:
Existing Ownership Summary New Ownership Summary
Date Request Received