Department of Alcoholic Beverage Control INDIVIDUAL PERSONAL AFFIDAVIT FINGERPRINTING (ABC USE ONLY) Active Livescan Date: 1. FIRST NAMEMIDDLE NAMELAST NAME2. PREVIOUS NAME(S) (Include maiden name, aka, alias) 3. PREMISES ADDRESS 4. PREMISES TELEPHONE NUMBER 5. HOME ADDRESS 6. HOME TELEPHONE NUMBER 7. SOCIAL SECURITY NUMBER 8. DRIVER'S LICENSE OR ID NUMBER9. STATE WHERE DL OR ID ISSUED10. WORK OR CELL TELEPHONE NUMBER 11. PERSONAL DATA HEIGHTWEIGHTEYE COLORHAIR COLOR Male Female 12. BIRTHDATE 13. BIRTHPLACE (City, State, Country)14. MARITAL STATUS Single DivorcedWidow(er) Married SeparatedRegistered Partner 15. SPOUSE'S/REGISTERED PARTNER'S NAME (Last, first, middle) (Include alias) 16. MARRIAGE DATE17. MARRIAGE PLACE (City, State) 18. I AM OR WILL BE Sole Owner General PartnerFood LesseeOfficerTitle: Limited Partner Spouse/Registered Partner Limited PartnerDirector LLC Member/Managing Member Partner ManagerStockholder 19.Do you now have any direct, or indirect, interest in any other alcoholic beverage business, or have you ever been an alcoholic beverage licensee or an officer or director of a corporate licensee in or outside of California? YesNo IF YES, EXPLAIN (List License number and/or premises address) 20.Have you as an individual, a partner, or while an officer, director, or stockholder of a corporation ever had an alcoholic beverage license denied, suspended, revoked, or an offer in compromise accepted or rejected? YesNo IF YES, EXPLAIN 21.EMPLOYMENT HISTORY (Past five years - include unemployed, student, homemaker, etc. Use additional sheets if needed.) FROM (MONTH/YEAR) TO (MONTH/YEAR)JOB TITLECOMPANY NAME AND CITY 22.Have you ever, anywhere or at any time, (1) forfeited bail, (2) been convicted, (3) fined, or (4) placed on probation for any violation of the law? (5) Are you now actively being prosecuted for a criminal offense? (If any of these events has occurred, this question must be answered "Yes" regardless of subsequent court action resulting in expungement, unless an order sealing records under Section 1203.45 of the Penal Code, relating to persons under age 18 years, has been issued. If no order has been issued, the answer must be "Yes.") YesNo ARREST DATE PLACE OF ARRESTOFFENSERESULT/DISPOSITION 23. FINANCIAL CONTRIBUTION TO THE BUSINESS (If Box B is checked, complete Form ABC-208-B) A.I am not making a contribution in any form C.I am contributing labor/expertise only B.I am making a financial contribution D.Same as the affidavit of I have read all of the above and declare under penalty of perjury that each and every statement is true, correct and complete. AFFIANT SIGNATURE TITLE DATE SIGNED PLACE SIGNEDATTEST (ABC EMPLOYEE OR NOTARY PUBLIC) ABC-208-A (rev. Instructions: This form must be completed by: sole owners and their spouses; each general partner and their spouses; officers of a corporation and a majority of the board of directors; persons holding 10% or more of the capital or stock of a corporation and their spouses; persons holding 10% or more of the capital or stock of a limited liability company or limited partnership and their spouses. If Item #23b is checked, you must complete Form ABC - 208 - B, Financial Affidavit. State of California Governor American LegalNet, Inc. www.FormsWorkFlow.com