PERSONAL HISTORY SHEET Answer all questions. Any false statement will disqualify you and subject you to prosecution under section 101.69 of the Texas Alcoholic Beverage Code and other criminal statutes. FORM L-40.3 (2/2010) 1. Trade Name: APPLICANT 2. Location Address: 3. Applicant’s Marital Status: Single Married Divorced 4. Applicant’s Social Security Number Issuing State/ Driver’s License No - Widowed Date of Birth (mm/dd/yyyy) / / Place of Birth (City, State, Country) Applicant’s Full Legal Name (Last, First, Middle) Applicant’s Email Address APPLICANT’S SPOUSE Race Sex Height 5. Spouse’s Social Security Number - Weight Hair Color Issuing State/ Driver’s License No Date of Birth (mm/dd/yyyy) / / Place of Birth (City, State, Country) Spouse’s Full Legal Name (Last, First, Middle) Race Sex Eye Color Height Weight Hair Color Eye Color RESIDENTIAL ADDRESSES OTHER RESIDENT 6. Do you live with anyone over the age of 18, other than your spouse? Full legal name (Last, First, Middle) RESIDENT STATUS YES NO Relationship Race Sex 7. List residential addresses for the past five (5) years starting with current address. If you have not lived in Texas for the previous 12 months, you are required to provide TABC with a certified copy of your criminal background check from the state police or FBI of any state where you lived in the previous five years. (If additional space is needed, please attach a list with the following information.) Number and Street City, State, ZIP From (mm/yyyy) To (mm/yyyy) / PRESENT / / / Area Code + Residential Phone No. ( ) - / / 8. Area Code + Business Phone No. ( ) - DIS TRICT O F F I C E 6. If “YES,” please provide their information below: (If additional space is needed, please attach a page with information.) Social Security Number Issuing State/ Driver’s License No Date of Birth (mm/dd/yyyy) / / / Area Code + Mobile Phone No. (optional) ( ) 9A. 9A. Are you a U.S. citizen? B. If “YES,” answer the following: Native Born Naturalized. If “Naturalized,” please provide the “A” Number here. A: C. If “NO,” answer the following: What is your legal status in the United States? Explain below, or attach a page with information. YES D. Provide all documents such as Visa, Resident Alien, Employment Authorization Documents, etc. (If additional space is needed, please attach a page with information.) APPLICANT YES CH - Date Entered / / NO ID # SPOUSE YES NO Date Verified / Supervisor’s Signature OTHER YES NO ID# Destroy Date / Page 1 of 2 Location Check / # / American LegalNet, Inc. www.FormsWorkFlow.com NO PERSONAL HISTORY SHEET FORM L-40.3 (2/2010) 10. List employment for the past five (5) years beginning with your current employer. Indicate periods of unemployment EMPLOYMENT H ISTOR Y or retirement, including dates. If retired, include name of company from which you retired and the position you held. Also indicate if not employed outside your home. (If additional space is needed, attach a separate sheet.) Name of Employer Address (Street, City, State, ZIP) Position Held From (mm/yyyy) To (mm/yyyy) / PRESENT / / / / / / / / / / INDIVIDUAL FINANCIAL INFORMATION 11. This section is for you to list the total amount of your personal investment in this location. Include notes, loans, gifts, cash, services or equipment, and operating capital. Provide investment details. Account for the original source of all investments (how acquired). Enter total dollar amount on the line of the amount invested column. (If additional space is needed, attach a separate sheet.) NOTE: If investment is in the form of a loan or gift, attach name of lender or financial institution, address, terms and security and loan/gift documents. If from an individual, attach personal information for all individuals including: Name, Social Security and Driver’s License Numbers, date of birth, race, sex, etc. Amount Invested Original Source of Investment (loans, previous employment, etc). $ $ $ $ $ $ TOTAL AMOUNT OF PERSONAL INVESTMENT $ SIGN AND NOTARIZE APPLICANT OATH SIGN AND NOTAR IZE WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: “…a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the penitentiary for not less than 2 nor more than 10 years.” I, under penalty of law, hereby swear that I have read all the information provided in this document and any attachments and the information is true and correct. I also understand any false statement or representation in this application can result in my application being denied and/or criminal charges filed against me. I also authorize the Texas Alcoholic Beverage Commission to use all legal means to verify the information provided. PRINT NAME: AUTHORIZED SIGNATURE: BEFORE ME, the undersigned authority, on this day of , 20 the person whose name is signed to the foregoing document personally appeared and duly sworn by me, each states under oath that he or she has read the said document and that all facts therein set forth are true and correct. SIGN HERE: (S E A L) Notary Public or TABC Agent Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com