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This is a Arizona form that can be used for Liquor Licenses And Control within Statewide.
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Arizona Department of Liquor Licenses and Control 800 W Washington 5th Floor Phoenix, AZ 85007-2934 www.azliquor.gov (602) 542-5141 QUESTIONNAIRE A.R.S.§4-202, 4-210 Type or Print with Black Ink The fees allowed by A.R.S.§4-6852 will be charged for all dishonored checks. Attention local governments: Social security and birth date information is confidential. This information may be given to law enforcement agencies for background checks only. Attention applicant: This is a sworn document. Type or print in black ink. An extensive investigation of your background will be conducted. False or incomplete answers could result in criminal prosecution and the denial or the subsequent revocation of a license or permit. QUESTIONNAIRE IS TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER. EACH PERSON COMPLETING THIS FORM MUST SUBMIT A FINGERPRINT CARD. FINGERPRINTS ON FBI APPROVED CARDS ARE ACCEPTED FROM THE DEPARTMENT OF LIQUOR, LAW ENFORCEMENT AGENCIES, OR A BONA FIDE FINGERPRINT SERVICE. FINGERPRINT FEES WILL VARY. IN ADDITION TO THE FINGERPRINT FEE OF $13 CHARGED BY THE DEPARTMENT OF LIQUOR, A $22.00 ARIZONA DEPARTMENT OF PUBLIC SAFETY BACKGROUND CHECK FEE PER FINGERPRINT CARD WILL ALSO BE CHARGED. Liquor License#: 1. Check the Appropriate Box (If the location is currently licensed) Controlling Person Agent (complete all questions) Manager (complete all questions except #12) 2. Name: ______________________________________________________________________________________ Birth Date: _____/_____/______ Last First Middle (NOT a public record) 3. Social Security #: ____________________________ Driver License#: _______________________________ State: ______________________ (NOT a public record) 4. Place of birth: _______________________________________________ Height: ________ Weight: ________ Eyes: _______ Hair: ________ City State COUNTRY (not county) 5. Name of current/most recent spouse: _________________________________________________________ Birth Date: _____/_____/_____ Last First Middle Maiden (NOT a public record) 6. Are you a bona fide resident of Arizona?Yes No If yes, what is your date of residency: _______________________________ 7. Daytime telephone number: ____________________________ E-mail address: ___________________________________________________ 8. Business Name: ________________________________________________________________________ Business Phone: _____/______/______ 9. Business Location Address: ________________________________________________________________________________________________ Street (do not use PO Box ) City State County Zip A.R.S. §4-202(A) and (C) 10. List your employment or type of business during the past five (5) years. If unemployed, retired, student list residence address. FROM Month/Year TO Month/Year CURRENT DESCRIBE POSITION OR BUSINESS EMPLOYERS NAME OR NAME OF BUSINESS (Street Address, City, State & Zip) (ATTACH ADDITIONAL SHEET IF NECESSARY) 11. Indicate your residence address for the last five (5) years: A.R.S. §4-202(D) 2/24/2017 Page 1 of 2 Individuals requiring ADA accommodations please call (602)542-9027 American LegalNet, Inc. www.FormsWorkFlow.com FROM Month/Year TO Month/Year CURRENT Rent or Own RESIDENTIAL Street Address City State Zip (ATTACH ADDITIONAL SHEET IF NECESSARY) 12. As a Controlling Person or Agent will you be physically present and operating the licensed premises? If you answered YES, then answer #13 below. If NO, skip to #14. 13. Have you attended a DLLC-approved Liquor Law Training Course within the past 3 years? (Must provide the DLLC-approved certificate of completion issued by a course provider.) 14. Have you been cited, arrested, indicted or summoned into court for violation of ANY law or ordinance, regardless of the disposition, even if dismissed or expunged, within the past five (5) years? (For traffic violations, include only those that are alcohol and/or drug related.) A.R.S. §4-202 15. Are there ANY administrative law citations, compliance actions or consents, criminal arrest, indictments or summonses pending against you? Include only criminal traffic tickets and complaints. A.R.S.§4-202,4-210 16. Has anyone EVER obtained a judgement against you, the subject of which involved fraud or misrepresentation. 17. Have you had a liquor application or license rejected, denied, revoked, suspended or fined in Arizona in? Yes No Yes No Yes No Yes No Yes No Yes No A.R.S. §4-202(D) If you answered "YES" to any Question 14 through 17 YOU MUST attach a signed statement. Give complete details including dates, agencies involved and dispositions. CHANGES TO THIS APPLICATION MAY NOT BE ACCEPTED Signature Block I, (Print Name) _________________________________________________, hereby declare that I am the Owner/Agent filing this application, I have read this document and verify the content and all statements are true, correct and complete, to the best of my knowledge. SIGNATURE: ___________________________________________________________ NOTARY State of Arizona County of ________________ Day ) ) ) Year (Print Name of Document Signer) On this _____Day of ____________, 20_______ before me personally appeared_______________________________ Month whose identity was proven to me on the basis of satisfactory evidence to be the person who he or she claims to be and acknowledged that he or she signed the above/attached document. ________________________________________________ Signature of NOTARY PUBLIC (Affix Seal Above) SIGNATURE FOR CONTROLLING PERSON OR AGENT APPROVING A MANAGER'S APPLICATION I, (Print Full Name) ______________________________________________________, hereby authorize the person named on this questionnaire to act as manager for the named liquor license. SIGNATURE: __________________________________________________________ 2/24/2017 Page 2 of 2 Individuals requiring ADA accommodations please call (602)542-9027 American LegalNet, Inc. www.FormsWorkFlow.com