Arizona > Statewide > Liquor Licenses And Control
Questionnaire LIC 0101 - Arizona
| Questionnaire Form. This is a Arizona form and can be used in Liquor Licenses And Control Statewide . |
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ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL 800 W Washington 5th Floor Phoenix AZ 85007-2934 (602) 542-5141 QUESTIONNAIRE Attention all Local Governing Bodies: Social Security and Birthdate Information is Confidential. This information may be given to local law enforcement agencies for the purpose of background checks only but must be blocked to be unreadable prior to posting or any public view. Read carefully. This instrument is a sworn document. Type or print with BLACK INK. An extensive investigation of your background will be conducted. False or incomplete answers could result in criminal prosecution and the denial or subsequent revocation of a license or permit. TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT, OR MANAGER. EACH PERSON COMPLETING THIS FORM MUST SUBMIT AN "APPLICANT" TYPE FINGERPRINT CARD AVAILABLE AT THIS OFFICE. FINGERPRINTS ON FBI-APPROVED CARDS ARE ACCEPTED FROM LAW ENFORCEMENT AGENCIES, BONA FIDE FINGERPRINT SERVICES, OR THE DEPARTMENT OF LIQUOR. THE DEPARTMENT CHARGES A $13 FEE. . Liquor License # The fees allowed by A.R.S. ยง 44-6852 will be charged for all dishonored checks. 1. Check appropriate box Controlling Person Agent (Complete Questions 1-19) Controlling Person or Agent must complete #21 for a Manager Last First Middle (If the location is currently licensed) Manager (Only) (Complete All Questions except # 14, 14a & 21) Controlling Person or Agent must complete # 21 (NOT a Public Record) 2. Name: _______________________________________________________________________ Date of Birth: ______/______/____________ 3 . Social Security Number:____________________________Drivers License #:__________________________ State:___________________ (NOT a public record) (NOT a public record) 4 . Place of Birth: ______________________________________________ Height: _______ Weight: _______ Eyes: _____ Hair:___________ City State Country (not county) 5. Marital Status Single Married Divorced Widowed Last First Middle Maiden (List all for last 5 years - Use additional sheet if necessary) 6. Name of Current or Most Recent Spouse: _____________________________________________________ Date of Birth: ____/____/______ (NOT a public record) 7. You are a bona fide resident of what state? ________________________________ If Arizona, date of residency: _______________________ 8 Telephone number to contact you during business hours for any questions regarding this document. 9. If you have been an Arizona resident for less than three (3) months, submit a copy of your Arizona driver's license or voter registration card. 10. Name of Licensed Premises: _______________________________________________ Premises Phone: 11. Physical Location of Licensed Premises Address: __________________________________________________________________________ Street Address (Do not use PO Box #) City County Zip 12. List your employment or type of business during the past five (5) years. If unemployed part of the time, list those dates. List most recent 1st. FROM Month/Year TO Month/Year CURRENT DESCRIBE POSITION OR BUSINESS EMPLOYER'S NAME OR NAME OF BUSINESS (street address, city, state & zip) ATTACH ADDITIONAL SHEET IF NECESSARY FOR EITHER SECTION 13. Indicate your residence address for the last five (5) years: Month/Year Month/Year FROM TO Rent or RESIDENTIAL Street Address Own If rented, attach additional sheet with name, address and phone number of landlord City State Zip CURRENT April 16, 2012 Disabled individuals requiring special accommodations, please call the Department. (602) 542-9027 American LegalNet, Inc. www.FormsWorkFlow.com If you checked the Manager box on the front of this form skip to # 15 14. As a Controlling Person or Agent, will you be physically present and operating the licensed premises? If you answered YES, how many hrs/day?________, and answer #14a below. If NO, skip to #15. 14a. Have you attended a DLLC-approved Liquor Law Training Course within the past 5 years? (Must provide proof) If the answer to # 14a is "NO", course must be completed before issuance of a new license or approval on an existing license. YES YES NO NO 15. Have you been cited, arrested, indicted or summoned into court for violation of ANY law or ordinance, regardless of the disposition, even if dismissed or expunged, within the past ten (10) years? In addition, please include all traffic tickets and complaints within the last ten (10) years that resulted in a warrant for arrest AND any traffic tickets and complaints that are alcohol or drug-related. 16. Are there ANY administrative law citations, compliance actions or consents, criminal arrest, indictments or summonses PENDING against you or ANY entity in which you are now involved? Include only criminal traffic tickets and complaints. 17. Have you or any entity in which you have held ownership, been an officer, member, director or manager EVER had a business, professional or liquor application or license rejected, denied, revoked, suspended or fined in this or any other state? 18. Has anyone EVER filed suit or obtained a judgment against you, the subject of which involved fraud or misrepresentation? 19. Are you NOW or have you EVER held ownership, been a controlling person, been an officer, member, director or manager on any other liquor license in this or any other state? If any answer to Questions 15 through 19 is "YES" YOU MUST attach a signed statement. Give complete details including dates, agencies involved, and dispositions. YES NO YES NO YES YES NO NO YES NO SUBSTANTIVE CHANGES TO THIS APPLICATION WILL NOT BE ACCEPTED 20. I, ______________________________________, hereby declare that I am the APPLICANT/REPRESENTATIVE filing this questionnaire. I have read this questionnaire and all statements are true, correct and complete. X --------------------------------------------------------------------------------------------------(Signature of Applicant) (print full name of Applicant) State of__________________County of ________________ The foregoing instrument was acknowledged before me this __________day of ______________________ , _______ Month Year My commission expires on: _________________________ Day Month Year __________________________________________ (Signature of NOTARY PUBLIC) ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ COMPLETE THIS SECTION ONLY IF YOU ARE A CONTROLLING PERSON OR AGENT APPROVING A MANAGER'S APPLICATION 21. The applicant hereby authorizes the person named on this questionnaire to act a
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