Ohio > Statewide > Department Of Commerce > Division Of Liquor Control
Officer Shareholders Disclosure Form DLC 4030 - Ohio
| Officer Shareholders Disclosure Form Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 Tussing Road, P.O. Box 4005, Reynoldsburg, Ohio 43068-9005 FOR OFFICE USE ONLY NEW PERMIT # TRANSFER Telephone: (614) 644-2431 - http://www.com.state.oh.us OFFICER/ SHAREHOLDERS DISCLOSURE FORM SECTION A. (This form must accompany all applications of a corporate business entity) DBA Name City, State Tax Identification No. (TIN) Zip Code Name of Corporation Permit Premises Address Township, if in Unincorporated Area SECTION B. 1. Is stock publicly traded? If "YES", indicate exchange ______________________________ & Do NOT complete SECTION D. 2. Does any stockholder own 5% or more shares? (If YES, complete section D) 3. Total Number of shares issued ____________________________. YES YES NO NO Please be advised that any social security numbers provided to the Division of Liquor Control in this application may be released to the Ohio Department of Public Safety, the Ohio Department of Taxation, the Ohio Attorney General, or to any other state or local law enforcement agency if the agency requests the social security number to conduct an investigation, implement an enforcement action, or collect taxes. SECTION C. List the top five (5) officers of the captioned corporation. If an office is NOT held please indicate by writing NONE. EACH OFFICER LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM NAME OF OFFICER SOCIAL SECURITY NUMBER DATE OF BIRTH 1) CEO 2) President 3) Vice-President 4) Secretary 5) Treasurer SECTION D. Stockholders holding 5% or more outstanding shares. Note: If you answered Question 1 YES, do not complete this section EACH SHAREHOLDER LISTED BELOW MUST SUBMIT A CIVILIAN IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM. If none, please indicate by writing NONE. 1) Stockholder's Name Residence Address City and State Telephone No. 2) Stockholder's Name Residence Address City and State Telephone No. Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth (PLEASE SEE REVERSE SIDE SHOULD YOU NEED ADDITIONAL SPACE TO LIST STOCKHOLDERS) STATE OF OHIO, ___________________________________________ COUNTYss, I, ___________________________________________________being first duly sworn, according to law, deposes and says that he/she is (Title) _____________________ of the ______________________________________________, a corporation duly authorized by law to do business in the State of Ohio, and that the statements made in the forgoing affidavit are true. (Signature) ___________________________________________________ (Print Name and Corporate Title) ________________________________________________ Sworn to and subscribed in my presence this __________________ day of _____________________________________________________, ________________________. ___________________________________________________________ (Notary Public) (Notary Expiration) DLC4030 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL 1-800-750-0750 REV. 5-06 American LegalNet, Inc. www.FormsWorkflow.com NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) Page 2 DLC 4030 (OFFICER / SHAREHOLDERS DISCLOSURE FORM) SECTION D. Stockholders holding 5% or more outstanding shares. (CONTINUED) Note: If you answered Question 1 "YES", do not complete this section EACH SHAREHOLDER LISTED BELOW MUST SUBMIT A IDENTIFICATION CARD & PERSONAL HISTORY BACKGROUND FORM If none, please indicate by writing NONE. 3) Stockholder's Name Residence Address City and State Telephone No. 4) Stockholder's Name Residence Address City and State Telephone No. 5) Stockholder's Name Residence Address City and State Telephone No. 6) Stockholder's Name Residence Address City and State Telephone No. 7) Stockholder's Name Residence Address City and State Telephone No. 8) Stockholder's Name Residence Address City and State Telephone No. 9) Stockholder's Name Residence Address City and State Telephone No. 10) Stockholder's Name Residence Address City and State Telephone No. Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth Social Security No. (if Individual) Tax Identification No. (if applicable) Zip Code Date of Birth NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) NUMBER OF SHARES HELD (NOT PERCENTAGE) American LegalNet, Inc. www.FormsWorkflow.com
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