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Individual Personal Affidavit (Must Also Complete For Officer Of A Corporation) ABC-208-A - California
| Individual Personal Affidavit (Must Also Complete For Officer Of A Corporation) Form. This is a California form and can be used in Department Of Alcoholic Beverage Control Statewide . |
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Department of Alcoholic Beverage Control INDIVIDUAL PERSONAL AFFIDAVIT Instructions: This form must be completed by: sole owners and their spouses; each general partner and their spouses; officers of a corporation and a majority of the board of directors; persons holding 10% or more of the capital or stock of a corporation and their spouses; persons holding 10% or more of the capital or stock of a limited liability company or limited partnership. If Item #23b is checked, you must complete Form ABC-208-B, Financial Affidavit. 1. FIRST NAME 3. PREMISES ADDRESS 5. HOME ADDRESS 7. SOCIAL SECURITY NUMBER 11. PERSONAL DATA 8. DRIVER'S LICENSE OR ID NUMBER HEIGHT WEIGHT 9. STATE WHERE DL OR ID ISSUED EYE COLOR 14. MARITAL STATUS MIDDLE NAME LAST NAME State of California Edmund G. Brown Jr., Governor FINGERPRINTING (ABC USE ONLY) Active Date: Livescan 2. PREVIOUS NAME(S) (Include maiden name, aka, alias) 4. PREMISES TELEPHONE NUMBER 6. HOME TELEPHONE NUMBER 10. WORK OR CELL TELEPHONE NUMBER HAIR COLOR Male 12. BIRTHDATE Female 13. BIRTHPLACE (City, State, Country) Single Married 15. SPOUSE'S/REGISTERED PARTNER'S NAME (Last, first, middle) (Include alias) 18. I AM OR WILL BE 16. MARRIAGE DATE Divorced Separated Widow(er) Registered Partner 17. MARRIAGE PLACE (City, State) Sole Owner General Partner Food Lessee Officer Title: Spouse/Registered Partner Limited Partner Director LLC Member/Managing Member Partner Manager Stockholder 19. Do you now have any direct, or indirect, interest in any other alcoholic beverage business, or have you ever been an alcoholic beverage licensee or an officer or director of a corporate licensee in or outside of California? Yes IF YES, EXPLAIN (List License number and/or premises address) No 20. Have you as an individual, a partner, or while an officer, director, or stockholder of a corporation ever had an alcoholic beverage license denied, suspended, revoked, or an offer in compromise accepted or rejected? Yes IF YES, EXPLAIN No 21. EMPLOYMENT HISTORY (Past five years - include unemployed, student, homemaker, etc. Use additional sheets if needed.) FROM (MONTH/YEAR) TO (MONTH/YEAR) JOB TITLE COMPANY NAME AND CITY 22. Have you ever, anywhere or at any time, (1) forfeited bail, (2) been convicted, (3) fined, or (4) placed on probation for any violation of the law? (5) Are you now actively being prosecuted for a criminal offense? (If any of these events has occurred, this question must be answered "Yes" regardless of subsequent court action resulting in expungement, unless an order sealing records under Section 1203.45 of the Penal Code, relating to persons under age 18 years, has been issued. If no order has been issued, the answer must be "Yes.") Yes ARREST DATE PLACE OF ARREST OFFENSE RESULT/DISPOSITION No 23. FINANCIAL CONTRIBUTION TO THE BUSINESS (If Box B is checked, complete Form ABC-208-B) A. I am not making a contribution in any form B. I am making a financial contribution C. I am contributing labor/expertise only D. Same as the affidavit of I have read all of the above and declare under penalty of perjury that each and every statement is true, correct and complete. AFFIANT SIGNATURE DATE SIGNED PLACE SIGNED TITLE ATTEST (ABC EMPLOYEE OR NOTARY PUBLIC) ABC-208-A (rev. 01-11) American LegalNet, Inc. www.FormsWorkFlow.com
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