executed and submitted by the individual owner of a sole proprietorship; by each partner (whether general or limited) of a partnership; by properly authorized officer or officers of a corporation; each manager, trustee or member of an unincorporated association, making application for license, and by any person about to become associated in any official capacity, or as a partner with any person licensed under this Act. The supplementary statement shall contain the following information and the information required by Sections 12 to 18, inclusive, which shall be sworn to and notarized; 1. Business name and address of applicant with which affiant is, or will be, associated. 2. Affiant's full name, business address, residence address and age. 3. Official title or scope of managerial duties, or otherwise indicate nature of connection of the affiant with the applicant above named.
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