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Licensee Professional Information Sheet Form. This is a Massachusetts form and can be use in Alcoholic Beverages Commission Statewide.
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Tags: Licensee Professional Information Sheet, Massachusetts Statewide, Alcoholic Beverages Commission
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
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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
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