Auxiliary Questionnaire Alcohol Beverage License Application {AT-103}

AUXILIARY QUESTIONNAIRE ALCOHOL BEVERAGE LICENSE APPLICATION Submit to municipal clerk. Individual's Full Name (please print) (last name) (first name) (middle name) Home Address (street/route) Post Office City State Zip Code Home Phone Number Age Date of Birth Place of Birth The above named individual provides the following information as a person who is (check one): Applying for an alcohol beverage license as an individual. A member of a partnership which is making application for an alcohol beverage license. (Officer/Director/Member/Manager/Agent) of (Name of Corporation, Limited Liability Company or Nonprofit Organization) which is making application for an alcohol beverage license. The above named individual provides the following information to the licensing authority: 1. How long have you continuously resided in Wisconsin prior to this date? 2. Have you ever been convicted of any offenses (other than traffic unrelated to alcohol beverages) for violation of any federal laws, any Wisconsin laws, any laws of any other states or ordinances of any county or municipality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, give law or ordinance violated, trial court, trial date and penalty imposed, and/or date, description and status of charges pending. (If more room is needed, continue on reverse side of this form.) 3. Are charges for any offenses presently pending against you (other than traffic unrelated to alcohol beverages) for violation of any federal laws, any Wisconsin laws, any laws of other states or ordinances of any county or municipality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, describe status of charges pending. 4. Do you hold, are you making application for or are you an officer, director or agent of a corporation/nonprofit organization or member/manager/agent of a limited liability company holding or applying for any other alcohol beverage license or permit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, identify. (Name, Location and Type of License/Permit) Yes No Yes No Yes No 5. Do you hold and/or are you an officer, director, stockholder, agent or employe of any person or corporation or member/manager/agent of a limited liability company holding or applying for a wholesale beer permit, brewery/winery permit or wholesale liquor, manufacturer or rectifier permit in the State of Wisconsin? . . . . . . . . . . If yes, identify. (Name of Wholesale Licensee or Permittee) (Address By City and County) Yes No 6. Named individual must list in chronological order last two employers. Employer's Name Employer's Address Employed From To Employer's Name Employer's Address Employed From To The undersigned, being first duly sworn on oath, deposes and says that he/she is the person named in the foregoing application; that the applicant has read and made a complete answer to each question, and that the answers in each instance are true and correct. The undersigned further understands that any license issued contrary to Chapter 125 of the Wisconsin Statutes shall be void, and under penalty of state law, the applicant may be prosecuted for submitting false statements and affidavits in connection with this application. Subscribed and sworn to before me this day of (Clerk/Notary Public) , 20 (Signature of Named Individual) My commission expires Printed on Recycled Paper AT-103 (R. 8-11) Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkFlow.com