Statement Of Financial Interest
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Statement Of Financial Interest Form. This is a Alaska form and can be use in Alcoholic Beverage Control Board Statewide.
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Tags: Statement Of Financial Interest, Alaska Statewide, Alcoholic Beverage Control Board
STATE OF ALASKA
ALCOHOLIC BEVERAGE CONTROL BOARD
STATEMENT OF FINANCIAL INTEREST
CONFIDENTIAL
TO BE COMPLETED BY EACH APPLICANT, EITHER INDIVIDUAL OR CORPORATE
AS 04.11.450(a) states that no person other than a licensee may have a direct or indirect financial interest in the
business for which the license is issued.
Applicant:
DBA:
EIN:
Location:
List each owner, shareholder, member in the boxes below:
List below persons, firms, lending institutions or corporations which have or may have any financial involvement
in furthering purchases of assets, revenues or operating capital for the licensed business operations.
PLEASE CHECK THE FOLLOWING BOX IF NO INSTITUTIONS.
NAME
ADDRESS
AMOUNT
NONE
PURPOSE
Under the penalties of perjury, I declare that I have examined this application, including accompanying
schedules and statements, and to the best of my knowledge and belief it is true, correct, and complete.
Signature of Applicant/Transferee
Subscribed and sworn to before me this
Day of
Date
FIS (Revised 07/12)
20
Notary Public in and for the State of Alaska
My commission expires
CONFIDENTIAL
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