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Personal History Background Form DLC 4121 - Ohio
| Personal History Background Form Form. This is a Ohio form and can be used in Division Of Liquor Control Department Of Commerce Statewide . |
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FOR OFFICE USE ONLY NEW PERMIT # TRANSFER OHIO DEPARTMENT OF COMMERCE - DIVISION OF LIQUOR CONTROL 6606 TUSSING ROAD, P.O. BOX 4005 REYNOLDSBURG, OHIO 43068-9005 PERSONAL HISTORY BACKGROUND FORM http://www.com.ohio.gov/liqr Please be advised that any social security numbers provided to the Division of Liquor Control on this form 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. The applicant is required to fill out Section A only. The Division of Liquor Control will conduct a background check with the local authorities, who will complete Section B. THE APPLICANT IS NOT TO PERFORM THIS CHECK, THEREFORE, DO NOT TAKE THIS FORM TO YOUR LOCAL POLICE AUTHORITY. SECTION A (PLEASE PRINT) Name (Last) (First) (Middle) Height ft. Weight in. Alias used or Maiden Name Male Female Phone # State Social Security # Residence Address Date of Birth Are you a US Citizen? YES City NO Place of Birth Zip Code Marital Status: Spouse's Name (Last) (First) (Middle) Permit Address: YOUR SIGNATURE BELOW, GIVING AUTHORIZATION FOR RECORD CHECK X PLEASE READ: The Division of Liquor Control will submit this form to the local authorities to conduct a background check and at that time Section B. will be completed. THE APPLICANT IS NOT TO PERFORM THIS CHECK, THEREFORE, DO NOT TAKE THIS FORM TO YOUR LOCAL POLICE AUTHORITY. SECTION (B) THIS SPACE FOR LAW ENFORCEMENT AGENCY USE Please complete the information below and either fax to (614) 644-3166, OR mail to Division of Liquor Control, 6606 Tussing Rd., Reynoldsburg, OH 43068-9005 1) Does applicant have a police record? YES NO If Yes , Give Details________________________________________________________________________________________ ________________________________________________________________________________________________________ 2) Does local police department know of any reason why permit should NOT be issued? (If YES, Please Attach Supporting Evidence) 3) Please complete the information below: Police Department Name YES NO Signature of Authorized Official (We cannot accept a stamped signature) Date Of Signature DLC 4121 EOE/ADA SERVICE PROVIDER FOR TTY USERS DIAL 1-800-750-0750 Rev. 4-11 American LegalNet, Inc. www.FormsWorkFlow.com
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