The Commonwealth of Massachusetts ALCOHOLIC BEVERAGES CONTROL COMMISSION FORM A LICENSEE PERSONAL INFORMATION SHEET THIS FORM MUST BE COMPLETED FOR EACH: _____ A. NEW LICENSE APPLICANT _____ B. APPOINTMENT OR CHANGE OF MANAGER IN A CORPORATION _____ C. TRANSFER OF LICENSE (RETAIL ONLY-SEC. 12 & SEC. 15) (Please check which transaction is the subject of an application accompanying this Form A.) PLEASE TYPE OR PRINT ALL INFORMATION ALL QUESTIONS MUST BE ANSWERED AND TELEPHONE NUMBERS PROVIDED OR APPLICATION WILL NOT BE ACCEPTED. 1. LICENSEE NAME______________________________________________________________________ (NAME AS IT WILL APPEAR ON THE LICENSE) 2. NAME OF (PROPOSED) MANAGER _______________________________________________________ 3. SOCIAL SECURITY NUMBER ____________________________________________________________ 4. HOME (STREET) ADDRESS _____________________________________________________________ 5. AREA CODE AND TELEPHONE NUMBER (S): (Give both, your home telephone and a number at which you can be reached during the day). DAY TIME # ________________________________ HOME#__________________________________ 6. PLACE OF BIRTH: __________________________ 7. DATE OF BIRTH: _______________________ 8. REGISTERED VOTER: _______ YES _______ NO 8A. WHERE ?: ___________________________ 9. ARE YOU A U. S. CITIZEN: 10. COURT AND DATE OF NATURALIZATION (IF APPLICABLE): ___________________________________ (Submit proof of citizenship and/or naturalization such as Voter=s Certificate, Birth Certificate or Naturalization Papers) _______ YES _______ NO American LegalNet, Inc. www.USCourtForms.com 1 11. FATHER’ NAME: ________________________ S 12. MOTHER’ MAIDEN NAME: _____________ S 13. IDENTIFY YOUR CRIMINAL RECORD, (Massachusetts, Military, any other State or Federal): ANY OTHER ARREST OR APPEARANCE IN CRIMINAL COURT CHARGED WITH A CRIMINAL OFFENSE REGARDLESS OF FINAL DISPOSITION: __________ YES __________ NO (MUST CHECK EITHER YES OR NO) IF YES, PLEASE DESCRIBE OFFENSE (S) SPECIFIC CHARGE AND DISPOSITION (FINE, PENALTY, ETC.) ______________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________________ 14. PRIOR EXPERIENCE IN THE LIQUOR INDUSTRY: IF YES, PLEASE DESCRIBE: ________ YES ________ NO ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 15. FINANCIAL INTEREST, DIRECT OR INDIRECT, IN THIS OR ANY OTHER LIQUOR LICENSE, OR CERTIFICATE: ____________ YES ____________ NO PERMIT IF YES, PLEASE DESCRIBE:______________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 16. EMPLOYMENT FOR THE LAST TEN YEARS (Dates, Position, Employer, Address and if known, Telephone Numbers): ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 17. HOURS PER WEEK TO BE SPENT ON THE LICENSED PREMISES: _____________________________ 18. I HEREBY SWEAR THAT UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE INFORMATION I HAVE GIVEN IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. BY:________________________________________________________ PROPOSED MANAGER SIGNATURE ___________________ DATE F:\FILES\MAUREEN.1\MAUREEN\FORMS\FORMA.WPD 9/99 American LegalNet, Inc. www.USCourtForms.com 2