L- Phs - Personal History Sheet (Texas Alcoholic Beverage Commission) Page 2
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1
2EMPLOYMENT HISTORY
10. List employment for the past five (5) years beginning with your current employer. 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.
(If 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.
List the total amount of your personal investment in this location. Provide investment details including notes, loans, gifts,
cash, services or equipment, and operating capital. 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 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 numbers, 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: “…a 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.”
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
Page 2 of 2
Form L-PHS (08/2016)
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