Official Federal Forms > Alcohol And Tobacco Tax And Trade Bureau (TTB)
Personnel Questionnaire-Alcohol And Tobacco Products TTB F 5000.9 - Official Federal Forms
| Personnel Questionnaire-Alcohol And Tobacco Products Form. This is a national form and can be used in Alcohol And Tobacco Tax And Trade Bureau (TTB) . |
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DEPARTMENT OF THE TREASURY ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB) OMB No. 1513-0002 (03/31/2012) DATE PERSONNEL QUESTIONNAIRE - ALCOHOL AND TOBACCO PRODUCTS I. SUPPLEMENTAL TO APPLICATION FOR PERMIT FILED BY: (Identify the business with application for permit, Brewer's Notice or Application to Operate Wine Premises on file with TTB.) 1. Business Name (Name of Owner, Partners, Corporation, 3. LLC, etc.) Business Mailing Address (No., Street, City, State, and ZIP Code or PO Box) 2. Business Telephone Number ( ) EXT II. INDIVIDUAL RELATED TO APPLICATION FILED BY BUSINESS IDENTIFIED IN SECTION I (Related individuals may be Owners, Officers, Directors, Members, Partners, etc. with connection to the business identified in Section I) 4. Your Full Name (Do not use initials) 11. Your Home Telephone Number ( 5. Name You Usually Use 13. Your Work Telephone Number ( 6. Have you ever been known by ANY other name? (Select Yes or No. If yes, provide nicknames, aliases) Yes No 7. If you are a married woman, give your full maiden name(s) & date(s) of marriage 17. Your Gender MALE FEMALE 20. Your Hair Color 8. Your Legal Residence (No., Street, City, State, and ZIP Code) 22. Your Father's Full Name FT. IN. 21. Your Eye Color LBS. 18. Your Height 19. Your Weight 15. Your Birth Date 16. Your Social Security No. ) Extension ) 12. Your Cellular/Mobile Telephone Number ( ) - 14. Your Place of Birth (City, State, Country) 23. Your Mother's Full Maiden Name 9. Your Work Address (No., Street, City, State, and ZIP Code) 24. Your Position or Title With the Business Listed In Section I. Check if Same as: Item 3 Item 8 10. Your Email Address (xxx@yyy.zzz) 25. Description of Your Duties or Relationship to the Business Listed in Section I. TTB F 5000.9 (08/2010) Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com OMB No. 1513-0002 (03/31/2012) III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY (TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful. Attach a separate sheet of paper if necessary to provide further explanations.) If the answer to any question in this section is "Yes," give full details in the area provided, under remarks or on a separate sheet, taking care to number the responses to correspond with the question. Convictions, arrests, or charges for minor traffic violations need not be reported. 26. Have you ever been arrested for any violation of any FEDERAL or STATE law related to LIQUOR or TOBACCO PRODUCTS ? Yes No Yes No Yes No Yes No 27. Have you ever been arrested for violation of any other FEDERAL or STATE law? 28. Have you ever been convicted of any FELONY or MISDEMEANOR under FEDERAL or STATE law? 29. Have you ever been compromised, by payment of penalties or otherwise, for any violation of any FEDERAL law relating to Internal Revenue or Customs taxation of DISTILLED SPIRITS, WINES, BEER, or TOBACCO PRODUCTS? 30. Has disapproval ever been given to any application or notice of intention to manufacture, use, store, rectify, bottle, distribute, sell, import, or transport ALCOHOL, DENATURED SPIRITS, DISTILLED SPIRITS, BEER, WINES, or TOBACCO PRODUCTS Yes filed by you or any firm or corporation of which you were proprietor or a partner, officer, director, principal stockholder, or No responsible employee? 30a. If your answer is "Yes," provide the name under which the application was filed and the reason(s) for disapproval. 31. Are you a United States of America citizen? 31a. If you are a naturalized citizen, provide the date and location where your naturalization papers were issued. 31b. If you are not a citizen, give your current citizenship status. Yes No 32. Have you as an individual or in connection with a partnership, LLC., firm or corporation ever been connected with a FEDERAL permit or approved notice to manufacture, use, store, rectify, bottle, distribute, sell, deal in, import or transport ALCOHOL, DENATURED SPIRITS, DISTILLED SPIRITS, BEER, WINES, or TOBACCO PRODUCTS? 32a. If your answer is "Yes," provide the following, as applicable: i. Registry or Permit Number, if known iv. Name and Address under which the approved permit/notice was issued Yes No ii. Period covered iii. If discontinued, when and why? v. If revoked, was settlement made of CIVIL liabilities incurred thereunder? Yes If "Yes," when? No If there were no liabilities, make a statement to that affect: TTB F 5000.9 (08/2010) Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com OMB No. 1513-0002 (03/31/2012) III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY continued (TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful. Attach a separate sheet of paper if necessary to provide further explanations.) 33.Have you ever been or are you now employed by any person, firm, LLC., or corporation manufacturing or exporting tax-exempt Yes TOBACCO PRODUCTS, producing, storing, rectifying, bottling, selling, importing, or dealing in DISTILLED SPIRITS, WINES, BEER, ALCOHOL, or DENATURED SPIRITS, using or distributing DENATURED SPIRITS, or using (other than for personal use) No DISTILLED SPIRITS or ALCOHOL? 33a. If your answer is "Yes," provide the following information: i. Period When Employed iii. Name and Address of Person, Firm, LLC., or Corporation ii. In What Capacity/Position 34. Your Employment History for the Past 10 Years (Include nature, periods, and addresses of self-employment) 34a. Period (From/ To - MM/YYYY) To: 34b. Position Held 34c. Name and Address of Employer (No., street, city, county, State, ZIP Code) Present From: To: From: To: From: To: From: To: From: 35. Are you rated by any commercial credit reporting agency? Yes No If your answer is "Yes" provide the name and address of the commercial credit reporting agency and details of your rating. TTB F 5000.9 (08/2010) Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com OMB No. 1513-0002 (03/31/2012) III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY continued (TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful. Attach a separate sheet of paper if necessary to provide further explanations.) 36. Your Residences for Past Ten (10)Years (Provide the Street Address, City, County, State, and ZIP Code) 36a. Period (From/ To - MM/YYYY) To: From: To: From: To: From: To: From: 37. Your I
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