PLCB-196 3/09 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD INDIVIDUAL QUESTIONNAIRE FOR OFFICERS, DIRECTORS, STOCKHOLDERS, BUSINESS TRUSTEES, LIMITED LIABILITY COMPANY MEMBER, LIMITED OR GENERAL PARTNERS (SEE REVERSE) 1. NAME OF LICENSEE/APPLICANT BUREAU OF LICENSING LICENSE NO. LID NO. 2. ADDRESS 3. NAME OF ENTITY 4. ADDRESS 5. NAME OF INDIVIDUAL 6. HOME ADDRESS 7. U.S. CITIZEN YES DATE OF BIRTH PLACE OF BIRTH NO IF LAWFUL ALIEN, ALIEN ID NO. IF NATURALIZED, GIVE DATE, PLACE AND CERTIFICATE NO. 8. CURRENT EMPLOYMENT DATES FROM TO ADDRESS NAME OF EMPLOYER PRESENT (a) Type of business 9. CONVICTION RECORD: The following is a record of all felony and misdemeanor convictions of the individual, officer, director or stockholder. (Attach separate sheet if necessary.) If there have been no such convictions, insert the word “NONE.” NAME DATE OF CONVICTION 10. ARE YOU OR YOUR SPOUSE: CHARGE DISPOSITION LOCATION OF COURT (COUNTY AND STATE) SPOUSE’S NAME YES NO (a) A director, officer, stockholder or creditor of any other Pennsylvania licensee or manufacturer (any entity involved in producing, manufacturing, distilling, rectifying or compounding liquor, alcohol, or malt or brewed beverage? (b) The owner, proprietor or lessor of any place licensed by the PLCB or in the equipment used by same? (c) Financially interested, either directly or indirectly, in the profits of any other business licensed by the PLCB or have any financial interest or connection with the same? (i.e. loans, mortgages) (d) The holder of any license issued by the PLCB? (e) A public official involved in the enforcement of penal laws, either by appointment or election? (f) The employee of any licensee? (g) If any "yes" answers to (a) through (f) apply to your spouse, are funds involved in this transaction held jointly? (h) Comment on any "yes" replies to (a) through (g): 11. WILL YOU BE ACTIVELY ENGAGED IN THIS BUSINESS? YES NO IF YES, GIVE DETAILS I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or §7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief. SIGNATURE TITLE DATE American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS The Bureau of Licensing will determine if a personal interview is required of natural persons involved in licenses issued by the Pennsylvania Liquor Control Board. If a personal interview is not required this form will be completed. The form may be used by a person who is an officer, director, or stockholder of a corporation; member of manager of a limited liability company; trustee of a business trust; or a Limited or General Partner. This person may reside in state or out of state. Answer all questions, even in the answer is "none" or "not applicable" and sign the form. A fee is not required. On lines 3 and 4, list the name and address of the entity in which you are involved, even if it is the same as the LICENSEE/APPLICANT. American LegalNet, Inc. www.FormsWorkflow.com