PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principal Place of Business)
3. Local or California Address (if different than #2)
4. State where Entity is Registered with Secretary of State If other than California, is the Entity also registered in California? Yes No
5. Type of Entity
Corporation Limited Liability Company Partnership Trust Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) Note: If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust, or other entity
________________________ Officer Director Member Manager [ n a m e ] General Partner Limited Partner
Other ___________________________
_______________________________ Officer Director Member Manager [ n a m e ] General Partner Limited Partner
Other __________________________
________________________________ Officer Director Member Manager [ n a m e ] General Partner Limited Partner
Other __________________________ 11
79350 Four Paths Lane, Bermuda Dunes CA 92203
CA
SAME DAY EXPRESS LLC dba Signature Sculpture
BRETT FIORE Type text here
100% INTEREST
Type text here
7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity
EXAMPLE
JANE DOE
[name of owner/investor]
50%, ABC COMPANY, Inc.
[percentage of beneficial interest in entity and
name of entity]
A.
[name of owner/investor]
[percentage of beneficial interest in entity and
name of entity]
B.
[name of owner/investor]
[percentage of beneficial interest in entity and
name of entity]
C.
[name of owner/investor]
[percentage of beneficial interest in entity and
name of entity]
D.
[name of owner/investor]
[percentage of beneficial interest in entity and
name of entity]
E.
[name of owner/investor]
[percentage of beneficial interest in entity
and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Disclosing Party, Printed Name, Title Date BRETT FIORE, Owner/Operator
06/20/22