State Beverage Alcohol Personnel Statement {ATT-17}

ATT-17 (Rev. 1/13) Georgia Department of Revenue Alcohol and Tobacco Division Telephone: (404) 417-4900 E-mail: ATDIV@dor.ga.gov GEORGIA ALCOHOL & TOBACCO PERSONNEL STATEMENT Submit online at https://gtc.dor.ga.gov (Please type or print) This form must be completed by the following persons and submitted with all liquor license applications: (1) licensee, (2) anyone with an ownership interest in the business, whether direct, indirect or beneficial, and (3) in the case of a corporation or other legal entity, all officers. This form may be required of others in the discretion of the Commissioner as provided under Regulations 560-2-2-.02 and 560-2-17-.04. EACH QUESTION MUST BE FULLY ANSWERED. If additional space is required, attach an additional sheet of paper. 1. 2. 3. LAST NAME DATE OF BIRTH FIRST NAME RACE [ MI SOCIAL SECURITY NO. ] MALE [ ] FEMALE HOME ADDRESS(Actual Physical Location of Residence; Do Not Use P.O. Box) CITY STATE ZIP +4 HOME PHONE 4. ADDRESS FOR DAY CONTACT - NUMBER AND STREET ( Do Not Use P.O. Box) CITY STATE ] YES [ ZIP +4 PHONE FOR DAY CONTACT 5. ARE YOU MARRIED? [ LAST NAME ] NO IF "YES", PROVIDE THE FOLLOWING FOR YOUR SPOUSE: MI FIRST NAME SOCIAL SECURITY NO. ] YES [ ] NO IF "YES", HOW LONG _____ YEARS _____MONTHS 6. 7. ARE YOU A RESIDENT OF GEORGIA? [ HAVE YOU EVER BEEN ARRESTED, INDICTED OR CONVICTED FOR ANY OFFENSE BY ANY LOCAL, STATE, FEDERAL, OR FOREIGN GOVERNMENTAL AUTHORITY? [ ] YES [ ] NO. IF "YES", GIVE FULL DETAILS. DO NOT INCLUDE MINOR TRAFFIC VIOLATIONS. GIVE REASONS CHARGED OR HELD, DATE, PLACE WHERE CHARGED AND DISPOSITION. FAILURE TO MAKE FULL DISCLOSURE IN RESPONSE TO THIS QUESTION MAY RESULT IN DENIAL OR SUBSEQUENT REVOCATION OF THE LICENSE. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 8. DO YOU CURRENTLY HAVE BENEFICIAL INTEREST IN ANY OTHER ALCOHOLIC BEVERAGE BUSINESS OTHER THAN THE BUSINESS FOR WHICH THIS APPLICATION IS BEING FILED? [ ] YES [ ] NO ("Beneficial Interest" as used here means: when a person holds the license in his own name or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest, or derives economic benefit from, or has control over a business.) IF "YES", COMPLETE THE FOLLOWING: ALCOHOL LICENSE NO. % AND TYPE INTEREST LEGAL BUSINESS NAME TRADE NAME /DBA NAME American LegalNet, Inc. www.FormsWorkFlow.com ATT-17 (Rev. 1/13) 9. HAVE YOU EVER HAD ANY BENEFICIAL INTEREST IN ANY OTHER ALCOHOLIC BEVERAGE BUSINESS IN THIS OR ANY OTHER STATE IN WHICH THE ALCOHOL LICENSE WAS DENIED OR REVOKED OR ANY OTHER DISCIPLINARY ACTION WAS TAKEN? [ ] YES [ ] NO ("Beneficial Interest" as used here means: when a person holds the license in his own name or when he has a legal, equitable or other ownership interest in, or has any legally enforceable interest or financial interest, or derives economic benefit from, or has control over a business.) IF "YES", COMPLETE THE FOLLOWING: ALCOHOL LICENSE NO. % AND TYPE INTEREST LEGAL BUSINESS NAME TRADE NAME /DBA NAME NUMBER AND STREET CITY COUNTY STATE ZIP+4 DESCRIBE WHAT ACTION WAS TAKEN: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 10. LIST THE FULL LEGAL NAMES AND CURRENT ADDRESSES OF ALL LIVING FAMILY MEMBERS DESIGNATED BELOW: FAMILY MEMBERS STREET CITY STATE ZIP FATHER: MOTHER: FATHER-IN-LAW: MOTHER-IN-LAW: BROTHERS: SISTERS: 11. WORK HISTORY (Complete for the last 10 years, starting with present or last employer and using additional sheets if necessary.) EMPLOYER JOB TITLE EMPLOYER DATES WORKED TYPE OF BUSINESS ADDRESS (Month & Year) From To (City & State) American LegalNet, Inc. www.FormsWorkFlow.com ATT-17 (Rev. 1/13) SIGNATURE SECTION BEFORE SIGINING THIS STATEMENT, CHECK ALL ANSWERS AND EXPLANATIONS TO SEE THAT YOU HAVE ANSWERED ALL QUESTIONS FULLY, COMPLETELY AND CORRECTLY. THIS STATEMENT IS TO BE EXECUTED UNDER OATH AND SUBJECT TO THE PENALTIES OF FALSE SWEARING, AND IT INCLUDES ALL ATTACHED SHEETS HEREWITH. STAMPED SIGNATURE IS NOT ACCEPTABLE. I, ____________________________________________________________, DO SOLEMNLY SWEAR, SUBJECT TO THE PENALTIES OF FALSE SWEARING, THAT THE STATEMENT AND ANSWERS MADE BY ME IN THE FOREGOING PERSONNEL STATEMENT ARE TRUE AND CORRECT. I FURTHER HEREBY AUTHORIZE THE GEORGIA DEPARTMENT OF REVENUE, ALCOHOL & TOBACCO DIVISION TO OBTAIN ANY CRIMINAL HISTORY RECORD INFORMATION PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY STATE OR LOCAL CRIMINAL JUSTICE AGENCY IN GEORGIA. ________________________________________ Signature I HEREBY CERTIFY THAT ______________________________________SIGNED HIS/HER NAME TO THE FOREGOING STATEMENT AFTER STATING TO ME UNDER OATH ADMINISTERED BY ME, THAT ALL STATEMENTS AND ANSWERS ARE TRUE AND CORRECT. THIS _____________ DAY OF ____________________________, __________. ___________________________________ Notary Public AFFIX SEAL American LegalNet, Inc. www.FormsWorkFlow.com