Personal History Sheet {L-PHS}

Page 1 of 2 Form L-PHS (10/2018) PERSONAL HISTORY SHEET L - PHS 1 0 /201 8 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. Single Married Divorced Widowed 4. Issuing cense Number Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country ) Race Sex Height Weight Hair Color Eye Color APPLICANT 5. urity Number Is su ing State/ Driver License Number Date of Birth (mm/dd/yyyy) 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 please provide their information below: (If additional space is needed, please attach a page with information.) Social Security Number Issui ng 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 live d in Texas for the previous 12 months, you are required to provide TAB C 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 att ach 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. citize n? YES NO B. If answer the following: Native Born Number C. If answer the following: What is y our legal status 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 U SE O NLY APPLICANT YES NO SPOUSE (BE/BG ONLY ) YES NO OTHER YES NO CH - Date Entered / / Destroy Date / / American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Form L-PHS (10/2018) EMPLOYMENT HISTORY 10. List employment for the past five (5) years beginning with your current employer. Indicate periods of unemployment , retirement or self - employment, including dates. If retired or self - employed, include name of company from which you retired or owned, and the position yo u held or type of business owned. Also indicate if not employed outside your home. (If additional space is needed, attach a separate sheet.) Name of Employer /Company Address (Street, City, State, ZIP) Position Held /Business Type From (mm/yyyy) To (mm/yyy y) 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 c apital. Account for the original source of all investments (how acquired). Enter 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 gi ft, 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, ra ce, 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 sta 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 imprisonm ent in the Texas Department of Criminal Justice for not less than 2 nor 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 l egal 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 t hat 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