ATT-17 (Rev. 10/10) GEORGIA DEPARTMENT OF REVENUE ALCOHOL & TOBACCO DIVISION P.O. BOX 49728 ATLANTA, GA 30359 GEORGIA ALCOHOL & TOBACCO PERSONNEL STATEMENT (Please type or print) This form must be completed by the following persons and submitted with all liquor license applications: (1) licensee, (2) anyone with an ownership interest in the business, whether direct, indirect or beneficial, and (3) in the case of a corporation or other legal entity, all officers. This form may be required of others in the discretion of the Commissioner as provided under Regulations 560-2-2-.02 and 560-2-17-.04. EACH QUESTION MUST BE FULLY ANSWERED. If additional space is required, attach an additional sheet of paper. 1 LAST NAME FIRST 2 DATE OF BIRTH 3 HOME ADDRESS (Actual Physical Location of Residence; Do Not Use P.O. Box) / / MI RACE CITY SOCIAL SECURITY NO. MALE OR STATE ZIP + 4 HOME PHONE ( 4 ) ADDRESS FOR DAY CONTACT – NUMBER AND STREET (Do not use P.O. Box) CITY STATE ZIP + 4 PHONE FOR DAY CONTACT ( 5 FEMALE ARE YOU MARRIED? LAST NAME YES NO IF “YES”, PROVIDE FOLLOWING FOR SPOUSE: FIRST MI ) SOCIAL SECURITY NO. 6 7 YES NO. IF “YES”, HOW LONG YEARS MONTHS ARE YOU A RESIDENT OF GEORGIA? HAVE YOU EVER BEEN ARRESTED, INDICTED, OR CONVICTED FOR ANY OFFENSE BY ANY LOCAL, STATE, FEDERAL, OR FOREIGN GOVERNMENTAL AUTHORITY? YES NO. IF “YES”, GIVE FULL DETAILS. DO NOT INCLUDE MINOR TRAFFIC VIOLATIONS. GIVE REASONS CHARGED OR HELD, DATE, PLACE WHERE CHARGED AND DISPOSITION. FAILURE TO MAKE FULL DISCLOSURE IN RESPONSE TO THIS QUESTION MAY RESULT IN DENIAL OR SUBSEQUENT REVOCATION OF THE LICENSE. 8 DO YOU CURRENTLY HAVE BENEFICIAL INTEREST IN ANY OTHER ALCOHOLIC BEVERAGE BUSINESS OTHER THAN THE BUSINESS YES NO FOR WHICH THIS APPLICATION IS BEING FILED? (“Beneficial Interest” as used here means: when a person holds the license in his own name or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest, or derives economic benefit from, or has control over a business.) IF “YES”, COMPLETE THE FOLLOWING: ALCOHOL LICENSE NO. % AND TYPE INTEREST LEGAL BUSINESS NAME TRADE NAME / DBA NAME 9 HAVE YOU EVER HAD ANY BENEFICIAL INTEREST IN ANY OTHER ALCOHOLIC BEVERAGE BUSINESS IN THIS OR ANY OTHER STATE IN WHICH THE ALCOHOL LICENSE WAS DENIED OR REVOKED OR ANY OTHER DISCIPLINARY ACTION WAS TAKEN? YES NO (“Beneficial Interest” as used here means: when a person holds the license in his own name or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest, or derives economic benefit from, or has control over a business.) IF “YES”, COMPLETE THE FOLLOWING: ALCOHOL LICENSE NO. % AND TYPE INTEREST LEGAL BUSINESS NAME TRADE NAME / DBA NAME NUMBER AND STREET CITY COUNTY STATE ZIP +4 DESCRIBE WHAT ACTION WAS TAKEN: American LegalNet, Inc. www.FormsWorkFlow.com 10 LIST THE FULL LEGAL NAMES AND CURRENT ADDRESSES OF ALL LIVING FAMILY MEMBERS DESIGNATED BELOW: FAMILY MEMBERS Father: STREET CITY STATE ZIP Mother: Father-in-Law: Mother-in-Law: Brothers: Sisters: 11 WORK HISTORY (Complete for the last 10 years, starting with present or last employer and using additional sheets if necessary.) EMPLOYER ADDRESS (City & State) EMPLOYER JOB TITLE TYPE OF BUSINESS DATES WORKED (Month & Year) To From SIGNATURE SECTION BEFORE SIGNING THIS STATEMENT, CHECK ALL ANSWERS AND EXPLANATIONS TO SEE THAT YOU HAVE ANSWERED ALL QUESTIONS FULLY, COMPLETELY AND CORRECTLY. THIS STATEMENT IS TO BE EXECUTED UNDER OATH AND SUBJECT TO THE PENALTIES OF FALSE SWEARING, AND IT INCLUDES ALL ATTACHED SHEETS HEREWITH. STAMPED SIGNATURE IS NOT ACCEPTABLE. , I, DO SOLEMNLY SWEAR, SUBJECT TO THE PENALTIES OF FALSE SWEARING, THAT THE STATEMENT AND ANSWERS MADE BY ME IN THE FOREGOING PERSONNEL STATEMENT ARE TRUE AND CORRECT. I FURTHER HEREBY AUTHORIZE THE GEORGIA DEPARTMENT OF REVENUE, ALCOHOL & TOBACCO DIVISION TO OBTAIN ANY CRIMINAL HISTORY RECORD INFORMATION PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY STATE OR LOCAL CRIMINAL JUSTICE AGENCY IN GEORGIA. Signature I HEREBY CERTIFY THAT SIGNED HIS/HER NAME TO THE FORGOING STATEMENT AFTER STATING TO ME UNDER OATH ADMINISTERED BY ME, THAT ALL STATEMENTS AND ANSWERS ARE TRUE AND CORRECT. THIS DAY OF , . NOTARY PUBLIC AFFIX SEAL American LegalNet, Inc. www.FormsWorkFlow.com