STATE OF WASHINGTON BUSINESS LICENSING SERVICE PO Box 9034 Olympia, Wa 98507-9034 Telephone: 1-800-451-7985 LICENSE NUMBER UBI NUMBER Personal/Criminal History Statement (Provide a copy of this form to each agency. See page 2) (For Liquor, Lottery, Gambling and Cigarette/Tobacco Wholesaler/Retailer Endorsements ) Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply. Type of Endorsements(s) you are applying for: LIQUOR GAMBLING BUSINESS NaME: (DBA or trade name) BUSINESS LOCaTION addRESS: Street or Route LOTTERY (complete page 1 only) CIGARETTE/TOBACCO Wholesaler/Retailer VAPOR PRODUCTS Delivery/Retailer/Sales City County State or Country Zip Code I AM A: (Check all that apply) SOLE PROPRIETOR PaRTNER CORPORaTE OffICER Title: STOCkHOLdER 10% or more Maiden City HOME PHONE: fINaNCIER MaNagER LLC MEMBER/MgR OTHER: SPOUSE NaME: (Last, First, Middle) HOME MaILINg addRESS: (Street or PO Box) State or Country: HOW LONg LIVINg aT HOME addRESS aBOVE: SOCIaL SECURITY NUMBER: County WORk/CELL PHONE: HaIR COLOR: Zip Code: HEIgHT: SEX: WEIgHT: MaLE RaCE: EYE COLOR: BIRTHdaTE: (Month, Day and Year) aRE YOU a U.S. CITIZEN? dRIVER'S LICENSE NUMBER & STaTE Of ISSUE: PORT Of ENTRY: Maiden daTE Of ENTRY: (Month, Day and Year) daTE Of MaRRIagE: (Month, Day and Year) fEMaLE If NO, give alien registration/entry visa/work permit number(s): 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 gaMBLINg LIQUOR LOTTERY OTHER LICENSE NUMBERS BUSINESS NAME STATE LAST YEAR HELD CRIMINAL HISTORY STATEMENT 5. Been placed on probation? 3. Been convicted? Have you EVER: 1. Been arrested or cited? 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 OFFENSE DATE OFFENSE CONFIDENTIAL CERTIFICATION daTE SIgNEd: CITY COUNTY STATE DISPOSITION AND DATE 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: PRINT NaME: SIgNaTURE: PRINT NaME: X PLaCE SIgNEd: (City, County and State) If applying for gambling license, elected chief executive officer or employer must also sign this form. X daTE SIgNEd: PLaCE SIgNEd: (City, County and State) BLS-700-301 PERS/CRIM HISTORY (09/02/16) PagE 1 Of 2 American LegalNet, Inc. www.FormsWorkFlow.com Continue on to the backside of this form. Personal/Criminal History Statement (Page 2) LICENSE NUMBER UBI NUMBER ADDITIONAL PERSONAL HISTORY PLaCE Of BIRTH: City OTHER NaMES USEd: PLaCE Of MaRRIagE: City MILITaRY SERVICE: (Branch and dates of service) E-MaIL addRESS: County COUNTRY Of MILITaRY SERVICE: faX NUMBER: County State or Country PREVIOUS SOCIaL SECURITY NUMBER: State or Country TYPE Of dISCHaRgE: Zip Code 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: EMPLOYER/SCHOOL: addRESS: (Street or Route) dates from - To: EMPLOYER/SCHOOL: addRESS: (Street or Route) dates from - To: EMPLOYER/SCHOOL: addRESS: (Street or Route) City County State or Country Zip Code TITLE: City County SUPERVISOR: State or Country Zip Code TITLE: City County SUPERVISOR: State or Country Zip Code TITLE: SUPERVISOR: 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: STREET addRESS: CITY: COUNTY: COUNTY: STaTE or COUNTRY: ZIP COdE: STaTE or COUNTRY: ZIP COdE: 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 GAMBLING COMMISSION PO BOX 42400 OLYMPIa Wa 98504-2400 CIGARETTE/TOBACCO PO BOX 43098 OLYMPIa Wa 98504-3098 for assistance or to request this document in an alternate format, visit http://business.wa.gov/BLS or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718. BLS-700-301 PERS/CRIM HISTORY (09/02/16) PagE 2 Of 2 American LegalNet, Inc. www.FormsWorkFlow.com