Personal Criminal History Statement
Personal Criminal History Statement Form. This is a Washington form and can be use in Liquor Control Board Statewide.
Tags: Personal Criminal History Statement, BLS-700-301, Washington Statewide, Liquor Control Board
Washington State Liquor Control Board Checklist for Completing a Personal/ Criminal History Statement Use this checklist to fill out the Personal/Criminal History Statement form. Filling out the Personal/Criminal History Statement form completely will help avoid delays in the processing of your application. If you have any questions, please call Customer Service at (360) 664-1600 Complete all sections of the form. Please print clearly or type. Fill in any sections that do not apply with “N/A,” indicating the section is “not applicable.” If you are not a US citizen, list your alien registration number/visa number or attach a copy of the document to the form. Fully complete the Residence Information section. List residences for the last 10 years, even if residences have been outside of the United States. Fully complete the Employment History section. List dates of employment for the last 10 years, even if employment has been outside of the United States. Include any unemployment information during the last 10 years. Mark “YES” or “NO” on the question about your criminal history in the Criminal History Statement section. Completely fill out the Criminal History Statement section. If you fail to disclose an offense, it may be counted against you as a non-disclosure. List all offenses, even as a juvenile. List all traffic tickets, come as close as you can to dates and places. You may note as “various speeding/parking tickets over the last 20 years” if you cannot recall exact dates. Use additional paper if necessary to provide the requested information. Attach to the Personal Criminal History Statement form. Sign and date the form, completing the “place signed” section. DEFINITIONS The Personal Statement section asks what type of a business entity you are applying as. Following are definitions to help you fill out this section. Sole Proprietor: A single individual or a legally married couple. Partner: An individual who has joined in agreement with another individual(s). LLC Member: An individual who is a member of a Limited Liability Company. LLC Manager: An individual who is a manager of a Limited Liability Company. Spouse: The spouse of a sole proprietor, partner, or Limited Liability Company member/manager. Corporate Officer: An individual who holds an office in a corporation. Stockholder: An individual who owns stock in a corporation. Financier: An individual who has loaned, gifted, or invested money into the business. 8/03 American LegalNet, Inc. www.FormsWorkflow.com MASTER LICENSE SERVICE DEPARTMENT OF LICENSING Telephone: (360) 664-1400 LICENSE NUMBER UBI NUMBER PERSONAL/CRIMINAL HISTORY STATEMENT (For Liquor, Lottery, Gambling and Cigarette Wholesaler/Tobacco Distributor Licenses ) Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply. (You must provide a copy of this form to each of the agencies you checked below.) Type of License(s) you are applying for: ❏ LIQUOR ❏ LOTTERY ❏ GAMBLING ❏ CIGARETTE WHOLESALER/TOBACCO DISTRIBUTOR BUSINESS NAME: (DBA or trade name) BUSINESS LOCATION ADDRESS: Street or Route I AM A: (Check all that apply) City County ❏ SOLE PROPRIETOR ❏ CORPORATE OFFICER ❏ PARTNER Title: ❏ STOCKHOLDER 10% or more State or Country ❏ FINANCIER ❏ MANAGER Zip Code ❏ LLC MEMBER/MGR ❏ OTHER: ❏ SPOUSE NAME: (Last, First, Middle) Maiden SOCIAL SECURITY NUMBER: HOME MAILING ADDRESS: (Street or PO Box) City County HOME PHONE: WORK/CELL PHONE: WEIGHT: EYE COLOR: HAIR COLOR: RACE: DRIVER’S LICENSE NUMBER & STATE OF ISSUE: State or Country: Zip Code: HOW LONG LIVING AT HOME ADDRESS ABOVE: HEIGHT: BIRTHDATE: (Month, Day and Year) SEX: ARE YOU A U.S. CITIZEN? ❏ MALE ❏ FEMALE PORT OF ENTRY: DATE OF ENTRY: (Month, Day and Year) Maiden If NO, give alien registration/entry visa/work permit number(s): DATE OF MARRIAGE: (Month, Day and Year) ❏ YES ❏ NO SPOUSE’S NAME: (Last, First, Middle) LICENSE HISTORY List any business licenses that you have ever held, currently applied for, or have been denied/revoked/suspended in any state. TYPE LICENSE NUMBERS BUSINESS NAME STATE LAST YEAR HELD GAMBLING LIQUOR LOTTERY OTHER CRIMINAL HISTORY STATEMENT 5. Been placed on probation? 1. Been arrested or cited? 3. Been convicted? 6. Forfeited bail or paid a fine over $25 (Include traffic fines)? 2. Been charged with a crime? 4. Been Jailed? You must answer "YES" if any of the above have occurred, even if charges were dismissed, deferred or changed. Explain each charge fully below and attach additional sheets as needed. False or incomplete information may result in denial, suspension or revocation of a license. You must include events that occurred while you were a juvenile. ❏ YES ❏ NO Have you EVER: OFFENSE DATE OFFENSE CITY COUNTY STATE DISPOSITION AND DATE CONFIDENTIAL CERTIFICATION I certify under penalty of perjury that all answers and statements on page 1 and 2 are true, correct and complete. I understand that untruthful or misleading answers are cause for denial of a license and/or revocation of any license granted. I hereby authorize investigation of my criminal history, financial records and other sources as necessary for licensing. SIGNATURE: X DATE SIGNED: PRINT NAME: If applying for gambling license, elected chief executive officer or employer must also sign this form. PLACE SIGNED: (City, County and State) DATE SIGNED: PLACE SIGNED: (City, County and State) SIGNATURE: X PRINT NAME: BLS-700-301 PERS/CRIM HISTORY (R/12/05)OR Page 1 of 2 Continue on to the backside of this form. American LegalNet, Inc. www.FormsWorkflow.com PERSONAL/CRIMINAL HISTORY STATEMENT (Page 2) LICENSE NUMBER UBI NUMBER Page 2 to be completed by applicants applying for Liquor, Gambling, Cigarette Wholesaler, and Tobacco Distributor Licenses. ADDITIONAL PERSONAL HISTORY PLACE OF BIRTH: City State or Country County OTHER NAMES USED: PREVIOUS SOCIAL SECURITY NUMBER: PLACE OF MARRIAGE: City County State or Country MILITARY SERVICE: (Branch and dates of service) COUNTRY OF MILITARY SERVICE: TYPE OF DISCHARGE: E-MAIL ADDRESS: Zip Code FAX NUMBER: EMPLOYMENT HISTORY List employment, self-employment, military, unemployment and school attendance for the last 10 consecutive years (including foreign residences). If more space is needed, attach additional sheets in the same format. Dates From - To: TITLE: SUPERVISOR: EMPLOYER/SCHOOL: ADDRESS: (Street or Route) Dates From - To: City County TITLE: State or Country Zip Code State or Country Zip Code State or Country Zip Code SUPERVISOR: EMPLOYER/SCHOOL: ADDRESS: (Street or Route) Dates From - To: City County TITLE: SUPERVISOR: EMPLOYER/SCHOOL: ADDRESS: (Street or Route) City County RESIDENCE INFORMATION You must list all places of residence for the last 10 consecutive years (include foreign residences). List current residence first. If more space is needed, attach additional sheets in same format. Dates From - To: STREET ADDRESS: CITY: Dates From - To: COUNTY: STATE OR COUNTRY: ZIP CODE: COUNTY: STATE OR COUNTRY: ZIP CODE: STREET ADDRESS: CITY: CERTIFICATION I certify under penalty of perjury that all answers and statements on page 1 and 2 are true, correct and complete. I understand that untruthful or misleading answers are cause for denial of a license and/or revocation of any license granted. I hereby authorize investigation of my criminal history, financial records and other sources as necessary for licensing. SIGNATURE: X PRINT NAME: DATE SIGNED: PLACE SIGNED: (City, County and State) APPLICANT: YOU MUST MAKE COPIES FOR EACH OF THE AGENCIES YOU HAVE CHECKED ON PAGE 1 OF THIS FORM LIQUOR CONTROL BOARD PO BOX 43098 OLYMPIA WA 98504-3098 LOTTERY COMMISSION PO BOX 43027 OLYMPIA WA 98504-3027 BLS-700-301 PERS/CRIM HISTORY (R/12/05)OR Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com GAMBLING COMMISSION PO BOX 42400 OLYMPIA WA 98504-2400 CIGARETTE/TOBACCO PO BOX 43098 OLYMPIA WA 98504-3098 If you need assistance through the Telecommunications Device for the Deaf, call TTY (360) 664-8885. To request this document in an alternate format for the visually impaired, call (360) 664-1400.