DR 8404-I (01/06/05) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE STREET RM 108A DENVER CO 80261 INDIVIDUAL HISTORY RECORD To be completed by each individual applicant, all general partners of a partnership, and limited partners owning 10% (or more) of a partnership; all officers and directors of a corporation, and stockholders of a corporation owning 10% (or more) of the stock of such corporation; all limited liability company MANAGING members, and officers or other limited liability company members with a 10% (or more) ownership interest in such company and all managers of a Hotel and Restaurant or a Tavern License. NOTICE: This individual history record provides basic information which is necessary for the licensing authority investigation. All questions must be answered in their entirety or your application may be delayed or not processed. EVERY answer you give will be checked for its truthfulness. A deliberate falsehood or omission will jeopardize the application as such falsehood within itself constitutes evidence regarding the character of the applicant. 1. Name of Business 2. Your Full Name (last, first, middle) 3. List any other names you have used. 4. Mailing address (if different from residence) Home Telephone 5. List all residence addresses below. Include current and previous addresses for the past five years. STREET AND NUMBER CITY, STATE, ZIP FROM TO Current Previous 6. List all current and former employers or businesses engaged in within the last five years (Attach separate sheet if necessary) NAME OF EMPLOYER ADDRESS (STREET, NUMBER, CITY, STATE, ZIP) POSITION HELD FROM TO 7. List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry. NAME OF RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE 8. Have you ever applied for, held, or had an interest in a State of Colorado Liquor or Beer License, or loaned money, furniture or fixtures, equipment or inventory, to any liquor or beer licensee? If yes, answer in detail. Yes No 9. Have you ever received a violation notice suspension or revocation, for a liquor law violation, or have you applied for or been denied a liquor or beer license anywhere in the U.S.? If yes, explain in detail. Yes No American LegalNet, Inc. www.FormsWorkflow.com 10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court or do you have any charges pending? Include arrests for DUI and DWAI. (If yes, explain in detail.) Yes No 11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a deferred sentence? (if yes, explain in detail.) Yes No 12. Have you ever had any STATE issued licenses suspended, revoked, or denied including a drivers license? (If yes, explain in detail.) Yes No PERSONAL AND FINANCIAL INFORMATION Unless otherwise provided by law in 24-72-204 C.R.S., information provided below will be treated as CONFIDENTIAL. Colorado liquor licensing authorities require the following personal information in order to determine your suitability for licensure pursuant to 12-47-307 C.R.S. 13a. Date of Birth b. Social Security Number SSN c. Place of Birth d. U.S. Citizen? Yes e. If Naturalized, State where h. Naturalization Certificate Number l. Height f. When i. Date of Certification m. Weight n. Hair Color o. Eye Color No g. Name of District Court j. If an Alien, Give Alien’s Registration Card Number k. Permanent Residence Card Number p. Sex q. Race r. Do you have a current Driver’s License? If so, give number and state Yes No 14. Financial Information. a. Total purchase price $ (if buying an existing business) or investment being made by the applying entity, corporation, partnership, limited liability company, other $ b. List the total amount of your investment in this business including any notes, loans, cash, services or equipment, operating capital, stock purchases and fees paid $ c. Provide details of Investment. You must account for the sources of ALL cash (how acquired). Attach a separate sheet if needed. Type: Cash, Services or Equipment Source:Name of Bank; Account Type and Number Amount d. Loan Information (attach copies of all notes or loans) Name of Lender and Account Number Address Term Security Amount 15. Give name of bank where business account will be maintained; Account Name and Account Number; and the name or names of persons authorized to draw thereon. Oath of Applicant I declare under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete to the best of my knowledge. Authorized Signature Title Date American LegalNet, Inc. www.FormsWorkflow.com