ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 400 W Congress #521 Tucson AZ 85701-1352 (520) 628-6595 QUESTIONNAIRE Attention all Local Governing Bodies: Social Security and Birthdate Information is Confidential. This information may be given to local law enforcement agencies for the purpose of background checks only but must be blocked to be unreadable prior to posting or any public view. Read carefully. This instrument is a sworn document. Type or print with black ink. An extensive investigation of your background will be conducted. False or incomplete answers could result in criminal prosecution and the denial or subsequent revocation of a license or permit. TO BE COMPLETED BY EACH OWNER, AGENT, PARTNER, STOCKHOLDER (10% OR MORE), MEMBER, OFFICER OR MANAGER. ALSO EACH PERSON COMPLETING THIS FORM MUST SUBMIT AN “APPLICANT” TYPE FINGERPRINT CARD WHICH MAY BE OBTAINED AT THE DEPT. FINGERPRINTING MUST BE DONE BY A BONA FIDE LAW ENFORCEMENT AGENCY OR A FINGERPRINTING SERVICE APPROVED BY THE DEPARTMENT OF LIQUOR. THE DEPARTMENT DOES NOT PROVIDE THIS SERVICE. Liquor License # Eff. 10/01/03 there is a $29.00 processing fee for each fingerprint card submitted. A service fee of $25.00 will be charged for all dishonored checks (A.R.S. 44.6852) ( If the location is currently licensed) 1. Check appropriate box Owner Partner Stockholder Member Officer Agent Other _____________________(Complete Questions 1-20 & 24) Licensee or Agent must complete # 25 for a Manager Manager(Only) (Complete All Questions except # 14, 14a & 25) Licensee or Agent must complete # 25 2. Name: _______________________________________________________________________ Date of Birth: Last First Middle (This Will Not Become a Part of Public Records) 3 . Social Security Number:____________________________Drivers License #:__________________________ State: (This Will Not Become a Part of Public Records) 4 . Place of Birth: ______________________________________________ Height: _______ Weight: _______ Eyes: _____ Hair: City State Country (not county) 5. Marital Status Single Married Divorced Widowed Residence (Home) Phone: ( ) - 6. Name of Current or Most Recent Spouse: _____________________________________________________ Date of Birth: (List all for last 5 years - Use additional sheet if necessary) Last First Middle Maiden 7. You are a bona fide resident of what state? ________________________________ If Arizona, date of residency: 8 Telephone number to contact you during business hours for any questions regarding this document. (_____)_________ 9. If you have been a resident less than three (3) months, submit a copy of driver's license or voter registration card. 10. Name of Licensed Premises: _______________________________________________ Premises Phone: ( ) - 11. Licensed Premises Address: Street Address (Do not use PO Box #) City County Zip 12. List your employment or type of business during the past five (5) years, if unemployed part of the time, list those dates. List most recent 1st. FROM Month/Year TO Month/Year DESCRIBE POSITION OR BUSINESS EMPLOYER'S NAME OR NAME OF BUSINESS (Give street address, city, state & zip) CURRENT ATTACH ADDITIONAL SHEET IF NECESSARY FOR EITHER SECTION 13. Indicate your residence address for the last five (5) years: FROM TO Month/Year Month/Year Rent or RESIDENCE Street Address Own If rented, attach additional sheet giving name, address and phone number of landlord City State Zip CURRENT LIC 0101 02/2005 Disabled individuals requiring special accommodations, please call the Department. (602) 542-9027 American LegalNet, Inc. www.FormsWorkflow.com If you checked the Manager box on the front of this form skip to # 15 14. As an Owner, Agent, Partner, Stockholder, Member or Officer, will you be physically present and operating the YES NO the licensed premises ? If you answered YES, how many hrs/day?_____, answer #14a below. If NO, skip to #15. YES NO 14a. Have you attended a Department approved Liquor Law Training Course within the last 5 years? (Must provide proof) If the answer to # 14a is “NO”, course must be completed before issuance of a new license or approval on an existing license. 15. Have you EVER been detained, cited, arrested, indicted or summoned into court for violation of ANY law or ordinance (regardless of the disposition even if dismissed or expunged)? For traffic violations, include only those that were alcohol and/or drug related. YES NO YES NO 17. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or summonses PENDING against you or ANY entity in which you are now involved? YES NO 18. Have you or any entity in which you have held ownership, been an officer, member, director or manager EVER had a business, professional or liquor APPLICATION OR LICENSE rejected, denied, revoked, suspended or fined in this or any other state? YES NO 19. Has anyone EVER filed suit or obtained a judgment against you in a civil action, the subject of which involved fraud or misrepresentation of a business, professional or liquor license? YES NO YES NO 16. Have you EVER been convicted, fined, posted bond, been ordered to deposit bail, imprisoned, had sentence suspended, placed on probation or parole for violation of ANY law or ordinance (regardless of the disposition even if dismissed or expunged)? For traffic violations, include only those that were alcohol and/or drug related. 20. Are you NOW or have you EVER held ownership, been a controlling person , been an officer, member, director, or manager on any other liquor license in this or any other state? If any answer to Questions 15 through 20 is "YES" YOU MUST attach a signed statement. Give complete details including dates, agencies involved and dispositions. If you checked the Manager box on the front of this form, fill in #21-23 and 24, all others skip the following box (21-23) and go to # 24 Manager Section 21. Have you attended a Department approved Liquor Law Training Course within the last 5 years? (Must provide proof) YES NO If the answer to #21 is “NO” course must be completed BEFORE ISSUANCE of a new license OR APPROVAL on an existing license. 22. Do you make payments to the licensee? YES NO If “yes”, how much? $_______ per month. Total debt to licensee $________ 23. Is there a formal written contract or agreement between you and the licensee relating to the operation or management of this business? YES NO If “yes”, attach a copy of such agreement 24. I, ______________________________________________________, hereby declare that I am the APPLICANT filing this questionnaire. (Print full name of Applicant) I have read this questionnaire and the contents and all statements are true, correct and complete. X___________________________________________________________ State of__________________County of The foregoing instrument was acknowledged before me this (Signature of Applicant) __________day of ______________________ , Day Month Year My commission expires on: _________________________ Day Month Year (Signature of NOTARY PUBLIC) FILL IN THIS SECTION ONLY IF YOU ARE A LICENSEE OR AGENT APPROVING A MANAGER APPLICATION Licensee or Agent Approval of Manager 25.I, (Print Licensee/Agent’s Name): Hereby authorize the applicant to act as manager for the named liquor license. State of___________________County of The foregoing instrument was acknowledged before me this X day of (Signature of LICENSEE/AGENT) Day Month Year My commission expires on: Day Month Year (Signature of NOTARY PUBLIC) American LegalNet, Inc. www.FormsWorkflow.com