PLCB-2018 4/98 I COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD REQUEST FOR CRIMINAL RECORD CHECK (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING TYPE OR PRINT LEGIBLY WITH INK DATE OF REQUEST LICENSE NO. FOR OFFICIAL USE ONLY LID NO. LID NO. 1. NAME OF APPLICANT/LICENSEE APPLICATION CATEGORY 2. TRADE NAME (IF ANY) 3. ADDRESS OF PREMISES 4. (POST OFFICE) (STREET, RURAL ROUTE, P.O. BOX NO.) ENDING YEAR CONTROL NO. (ZIP) (STATE) 5. NAME (SUBJECT OF RECORD CHECK) (LAST) (FIRST) (MIDDLE) TITLE/POSITION 6. MAIDEN NAME AND/OR ALIASES SOCIAL SECURITY NO. (SOC) DATE OF BIRTH (DOB) SEX RACE M SIGNATURE TITLE/POSITION HOME ADDRESS PHONE F ( REQUESTER CHECKLIST AFTER COMPLETION MAIL TO: ) DID YOU ENTER THE FULL NAME, DOB, AND SOC? DID YOU ENCLOSE THE $10.00 FEE (CHECK/MONEY ORDER) PAYABLE TO "PLCB" OR "COMMONWEALTH OF PA"? DO NOT SEND CASH. PENNSYLVANIA LIQUOR CONTROL BOARD P O BOX 8940 HARRISBURG PA 17105-8940 DID YOU ENTER YOUR COMPLETE ADDRESS INCLUDING ZIP CODE AND TELEPHONE NUMBER IN THE BLOCKS PROVIDED? DO NOT WRITE BELOW THIS LINE INFORMATION DISSEMINATED INQUIRY BY DATE INQUIRED NO RECORD CRIMINAL RECORD THE INFORMATION DISSEMINATED BY THE CENTRAL REPOSITORY IS BASED SOLELY CERTIFIED BY ON THE FOLLOWING IDENTIFIERS THAT MATCH THOSE FURNISHED BY THE REQUESTER NAME SOC DATE OF BIRTH MAIDEN/ALIAS NAME RACE SEX American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS A records check is required by PA Title 40, Section 3.35. Form PLCB-2018, Request for Criminal Record Check AND a $10.00 fee must be submitted for each person involved in any of the following types of actions: 1. An application for a new license, either retail or wholesale, and certain types of licenses expiring December 31st. 2. Application for Transfer of License and Permit, except for the transfer of an existing license from one premises to another premises, PLCB-21. 3. Notice of Change of Officers, Directors and Manager or Steward of Club, PLCB-868. 4. Notice of Change in the Officers, Directors, Stockholders or Manager of Licensed Corporations, Except Clubs, PLCB-866. 5. Application for Approval of Appointment of Manager, PLCB-706. Upon receipt, the records check will be conducted via a direct link with the Pennsylvania State Police. Should you have any questions, contact the Bureau of Licensing at (717) 783-8250. INFORMATION If this form is part of an application for a new license, transfer of any existing license, or appointment of manager, or change of officers, it should be mailed with that application packet. However, if being submitted after the application, previously described, send it with the appropriate fee to: PENNSYLVANIA LIQUOR CONTROL BOARD, BUREAU OF LICENSING, P.O. BOX 8940, HARRISBURG, PA 171058940. American LegalNet, Inc. www.USCourtForms.com