Page 1 of 2 Form L-PHS (0/201) PERSONAL HISTORY SHEET L-PHS0/201 Answer all questions. Any false statement will disqualify you and subject you to prosecution under section 101.69 of the Texas Alcoholic Beverage Code and other criminal statutes. A PPLICANT 1. Trade Name: 2. Location Address: 3. Applicant222s Marital Status: Single Married Divorced Widowed 4. Applicant222s Social Security Number Issuing State/ Driver222s License Number Date of Birth (mm/dd/yyyy) Applicant222s Full Legal Name (Last, First, Middle) Place of Birth (City, State, C ountry ) Applicant222s Email Address Race Sex Height Weight Hair Color Eye Color APPLICANT 222S SPO USE 5. Spouse222s Social Security Number Is su ing State/ Driver License Number Date of Birth (mm/dd/yyyy) Spouse222s Full Legal Name (Last, First, Middle) Place of Birth (City, State, Country ) Race Sex Height Weight Hair Color Eye Color OTHER RESIDENT 6. Do you live with anyone over the age of 18, other than your spouse? 6. YES NO If 223YES,224 please provide their information below: (If additional space is needed, please attach a page with information.) Social Security Number Issuing State/ Driver License No . Date of Birth (mm/dd/yyyy) Relationship Full legal name (Last, First, Middle) Race Sex RESIDENTIAL ADDRESSES 7. List residential addresses for the past five (5) years starting with current address. If you have not lived in Texas for t he previous 12 months, you are required to provide TABC with an official copy of your criminal background check from the state police or FBI of any state where you lived in the previous five years. (If additional space is needed, please attach a list with the following information.) Number and Street City, State, ZIP From (mm/yyyy) To (mm/yyyy) PRESENT 8. Business Phone No . Residential Phone No . Mobile Phone No. (optional) RESIDENT STATUS 9A. Are you a U.S. citizen? YES NO B. If 223YES,224 answer the following: Native Born Naturalized. If 223Naturalized,224 Provide the 223A224 Number C. If 223NO,224 answer the following: What is your legal s tatus in the United States? Explain below, or attach a page with information. D. Provide all documents such as Visa, Resident Alien, Employment Authorization Documents, etc. TABC USE O NLY APPLICANT YES NO SPOUSE (BE/BG ONLY) YES NO OTHER YES NO CH - Date Entered / / Supervisor222s Signature Destroy Date / / American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Form L-PHS (0/201) EMPLOYMENT HISTORY 10. List employment for the past five (5) years beginning with your current emplo yer. Indicate periods of unemployment or retirement, including dates. If retired, include name of company from which you retired and the position you held. Also indicate if not employed outside your home. (I f additional space is needed, attach a separate sheet.) Name of Employer Address (Street, City, State, ZIP) Position Held From (mm/yyyy) To (mm/yyyy) PRESENT INDIVIDUAL FINANCIAL INFORMATION 11. L ist the total amount of your personal investment in this location. Provide investment details including notes, loans, gifts, cash, services or equ ipment, and operating capital. Account for the original source of all investments (how acquired). Ent er total dollar amount on the line of the amount invested column. (If additional space is needed, attach a separate sheet.) NOTE : If investment is in the form of a loan or gift, attach name of lender or financial institution, address, terms and security and loan/gift documents. If from an individual, attach personal information for all individuals including: name, social security and driver license n umbers, date of birth, race, sex, etc. Amount Invested Original Source of Investment (loans, previous employment, etc). $ $ $ $ $ $ $ TOTAL AMOUNT OF PERSONAL INVESTMENT SIGN AND NOTARIZE APPLICATION WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: 223205a person who makes a false statement or false representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and required to be sworn commits an offense punishable by imprisonment in the Texas Department of Criminal Justice for not less than 2 nor more than 10 years.224 I, under penalty of law, hereby swear that I have read all the information provided in this document and any attachments and the information is true and correct. I also understand any false statement or representation in this application can result in my application being denied and/or criminal charges filed against me. I also authorize the Texas Alcoholic Beverage Commission to use all legal means to verify the information provided. PRINT NAME: AUTHORIZED SIGNATURE: BEFORE ME, the undersigned authority, on this day of , 20 the person whose name is signed to the foregoing document personally appeared and duly sworn by me, each states under oath that he or she has read the said document and that all facts therein set forth are true and correct. SIGN HERE: (S E A L) Notary Public American LegalNet, Inc. www.FormsWorkFlow.com
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