Personal History Background Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Personal History Background Form, DLC 4121, Ohio Statewide, Department Of Commerce
FOR OFFICE USE ONLY OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 TRANSFER NEW PERSONAL HISTORY BACKGROUND FORM PERMIT # http://www.com.ohio.gov/liqr Please be advised that any social security numbers provided to the Division of Liquor Control on this form may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. The applicant is required to fill out Section A only. The Division of Liquor Control will conduct a background check with the local authorities, who will complete Section B. THE APPLICANT IS NOT TO PERFORM THIS CHECK, THEREFORE, DO NOT TAKE THIS FORM TO YOUR LOCAL POLICE AUTHORITY. SECTION A (PLEASE PRINT) Name (Last) (First) Alias used or Maiden Name Male Female Residence Address Date of Birth Marital Status: YES Weight in. Social Security # Phone # State City Are you a US Citizen? Height ft. (Middle) NO Zip Code Place of Birth Spouse's Name (Last) (First) (Middle) Permit Address: YOUR SIGNATURE BELOW, GIVING AUTHORIZATION FOR RECORD CHECK X PLEASE READ: The Division of Liquor Control will submit this form to the local authorities to conduct a background check and at that time Section B. will be completed. THE APPLICANT IS NOT TO PERFORM THIS CHECK, THEREFORE, DO NOT TAKE THIS FORM TO YOUR LOCAL POLICE AUTHORITY. THIS SPACE FOR LAW ENFORCEMENT AGENCY USE SECTION (B) Please complete the information below and either fax to (614) 644-3166, OR mail to Division of Liquor Control, 6606 Tussing Rd., Reynoldsburg, OH 43068-9005 1) Does applicant have a police record? YES NO If Yes , Give Details________________________________________________________________________________________ ________________________________________________________________________________________________________ 2) Does local police department know of any reason why permit should NOT be issued? (If YES, Please Attach Supporting Evidence) YES NO 3) Please complete the information below: Police Department Name Signature of Authorized Official (We cannot accept a stamped signature) DLC 4121 EOE/ADA SERVICE PROVIDER Date Of Signature FOR TTY USERS DIAL 1-800-750-0750 Rev. 4-11 American LegalNet, Inc. www.FormsWorkFlow.com