Applicant Of Controlling Person Affidavit
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Applicant Of Controlling Person Affidavit Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Applicant Of Controlling Person Affidavit, LIC0107, Arizona Statewide, Liquor Licenses And Control
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3. There are, in addition to those submitting questionnaires and fingerprint cards, other officers,
limited liability members, and/or board members of this organization who are not submitting such
information to the Arizona Department of Liquor Licenses and Control. None of these individuals
directs or is involved in the direction of the management of policies of this organization involving
spirituous liquor in the State of Arizona.
Such members and positions, along with date and place of birth, are as follows (or list attached):
(1)
(2)
(3)
(4)
4. None of the individuals listed under item #3 possesses the power to vote ten percent (10%) of the
outstanding voting securities of this organization, nor can any of them control the election of one or
more of the Board of Directors or managing members of the organization.
5. Finally, on information and belief, none of the individuals listed under item #3 have at any time
been convicted of a felony, had a liquor license revoked, or violated any provisions of a liquor
license issued to that member.
DATED this
day of
Day
,
Month
I,
Year
, declare that I am the APPLICANT filing this notification. I have
(Print full name)
read this document and the contents and all statements are true, correct and complete.
State of
County of
The foregoing instrument was acknowledged before me this
X
(Signature)
day of
Day
,
Month
Year
My commission expires on:
(Date)
(Signature of NOTARY PUBLIC)
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