INDIVIDUAL HISTORY WHO MUST COMPLETE THIS FORM? You must complete this form if on the LIQUOR LICENSE APPLICATION: Your name is listed as an applicant in the “Entity or Individuals applying for the license” section A corporation is listed as an applicant in the “Entity or Individuals applying for the license” section and you are: President; a Vice President with responsibility over the operation of the business; Secretary; or A Director who owns or controls 3% or more of the voting stock Treasurer A person holding or controlling 10% or more of any issued stock A limited liability company (LLC) is listed as an applicant in the “Entity or Individuals applying for the license” section Member of the LLC (this is a person designated to manage the LLC; it may or may not A Managing and you are: A Member who ownsdesignated to manage the business) be the same person or controls 10% or more of the membership IN ADDITION, THE OLCC MAY REQUIRE THE FOLLOWING PEOPLE TO COMPLETE THIS FORM: A person who is a manager. This is a person who has decision-making authority for the business and whose primary duties include controlling the operation of the licensed premises and its employees regarding the sale/service of alcoholic beverages. Other persons when there is reason to believe it may help the OLCC in its investigation. DIRECTIONS FOR COMPLETING FORM 1. Please print or type in ink. The OLCC must be able to read your form. 2. If the question doesn’t apply, write N/A in the space. 3. Attach additional sheets when necessary. IH Instructions 1-800-452-OLCC (6522) www.oregon.gov/OLCC (rev. 07/11) OREGON LIQUOR CONTROL COMMISSION INDIVIDUAL HISTORY 1. Trade Name ____________________________________________ 2. City _______________________ ___ 3. Name _________________________________________________________________________________ (Last) (First) (Middle) 4. Other names used (maiden, other) __________________________________________________________ 5. *SSN ____ - ____ - ____ 6. Place of Birth _________________ 7. DOB _____/____/_____ 8. Sex M (State or Country) (mm) F (dd) (yyyy) *SOCIAL SECURITY NUMBER DISCLOSURE: As part of your application for an initial or renewal license, Federal and State laws require you to provide your Social Security Number (SSN) to the Oregon Liquor Control Commission (OLCC) for child support enforcement purposes (42 USC § 666(a)(13) & ORS 25.785). The OLCC will refuse a license to any applicant or licensee who fails to provide his/her SSN. Your SSN will be used only for child support enforcement purposes unless you sign below. Based on our authority under ORS 471.311 and OAR 845-005-0312(6), we are requesting your voluntary consent to use your SSN for the following administrative purposes only: to match your license application to your Alcohol Server Education records (where applicable), and to ensure your identity for criminal records checks. OLCC will not deny you any rights, benefits or privileges otherwise provided by law if you do not consent to use of your SSN for these administrative purposes (5 USC§ 552(a). If you consent to these uses, please sign here: Applicant Signature:______________________________________________________________________________ _ 9. Driver License or State ID # __________________________________10. State _____________________ 11. Residence Address _____________________________________________________________________ (number and street) (city) (state) (zip code) 12. Mailing Address (if different) ______________________________________________________________ (number and street) (city) (state) (zip code) 13. Contact Phone __________________________ 14. E-Mail address (optional) ______________________ _ 15. Do you have a spouse or domestic partner? No Yes If yes, list his/her full name: _______________________________________________________________ Will this person work at or be involved in the operation or management of the business? 17. List all states, other than Oregon, where you have lived during the past ten years: _____________________________________________________________________________________ 18. In the past 12 years, have you been convicted (“convicted” includes paying a fine) in Oregon or any other state of driving a car with a suspended driver’s license or driving a car with no insurance? No Yes Unsure If yes, list the date(s), or approximate dates, and type(s) of convictions. If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ 19. In the past 12 years, have you been convicted (“convicted” includes paying a fine) in Oregon or any other state of a misdemeanor or a felony ? No Yes Unsure If yes, list the date(s), or approximate dates, and type(s) of convictions. If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ IH Form - Page 1 of 2 1-800-452-OLCC (6522) www.oregon.gov/OLCC ((rev. 07/11) 20. Trade Name _________________________________________ 21. City __________________________ 22. Do you have any arrests or citations that have not been resolved? No Yes If yes or unsure, explain here or include the information on a separate sheet. Unsure _____________________________________________________________________________________ 23. Have you ever been in a drug or alcohol diversion program in Oregon or any other state? (A diversion program is where you are required, usually by the court or another government agency, to complete certain requirements in place of being convicted of a drug or alcohol-related offense.) No Yes Unsure If yes, list the date(s), or approximate dates. If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ 24. Do you, or any legal entity that you are a part of, currently hold or have previously held a liquor license in Oregon or another US state? (Note: a service permit is not a liquor license.) No Yes Unsure If yes, list the name(s) of the business, the city (or cities) and state (or states) where located, and the date(s) of the license(s). If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ 25. Have you, or any legal entity that you are a part of, ever had an application for a license, permit, or certificate denied or cancelled by the OLCC or any other governmental agency in the US? No Yes Unsure If yes, list the date(s), or approximate dates. If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ Questions 2 and 2 apply if you, or any legal entity that you are part of, are applying for a Full On-Premises, Limited On-Premises, Off-Premises, or Brewery-Public House license. If you are not applying for one of those licenses, mark “N/A” on Questions 2 & 2 . 26. Do you have any ownership interest in any other business that makes, wholesales, or distributes alcohol? N/A No Yes Unsure If yes, list the date(s), or approximate dates. If unsure, explain. You may include the information on a separate sheet. _____________________________________________________________________________________ 27. Does, or will, a maker, wholesaler, or distributor of alcohol have any ownership interest in your business? N/A No Yes Unsure If yes or unsure, explain: _____________________________________________________________________________________ Question 2 applies if you, or any legal entity that you are part of, are applying for a Brewery, Brewery-Public House, Distillery, Grower Sales Privilege, Warehouse, Wholesale Malt Beverage & Wine, or Winery license. If you are not applying for one of those licenses, mark “N/A” on Question 2 . 28. Do you, or any legal entity that you are part of, have any ownership interest in any other business that sells alcohol at retail in Oregon? N/A No Yes Unsure If yes or unsure, explain: _____________________________________________________________________________________ You must sign your own form (you can’t have your attorney or a person with power of attorney sign your form). I affirm that my answers are true and complete. I understand the OLCC will use the above information to check my records, including but not limited to, criminal history. I understand that if my answers are not true and complete, the OLCC may deny my license application. Applicant Signature: ________________________________________________ Date: __________________ IH Form - Page 2 of 2 1-800-452-OLCC (6522) www.oregon.gov/OLCC ((rev. 07/11)