Investor Financial Form - Board Of License Commissioners, Anne Arundel County

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BOARD OF LICENSE COMMISSIONERS
FOR ANNE ARUNDEL COUNTY
2660 RIVA ROAD, SUITE 360
ANNAPOLIS, MARYLAND 21401
INVESTOR FINANCIAL INFORMATION
THIS FORM MUST BE FILED WITH ALCOHOLIC BEVERAGE LICENSE APPLICATION
Investor’s Name _______________________________________________________________
Address____________________________________________________ How Long? _______
Social Security Number __________________________ Date of Birth ___________________
Marital Status __________________________ Number of Dependents __________________
Most Recent Employer___________________ Address_______________________________
Position of Title_________________________ Gross Annual Income____________________
Type of Business________________________ How Long Employed ____________________
List any business interests and any other sources of income _________________________
_____________________________________________________________________________
List all banks with which you do business:
Type of Account:
____________________________________
_____________________________________
____________________________________
_____________________________________
____________________________________
_____________________________________
I am or will be the
owner
partner
member
stockholder
in the license business. If a stockholder/member, how many shares/percentage? _______
Lease
own
business premises.
My total personal contribution will be $ ___________. Of this amount $__________ will be
in cash and will be or has been derived from the following source(s): _________________
_____________________________________________________________________________
I UNDERSTAND THAT FALSIFICATION OF THE INFORMATION ON THIS FORM MAY
CONSTITUTE GROUNDS FOR DENIAL OR REVOCATION OF THE LICENSE.
I hereby authorize the Board of License Commissioners, or any of it’s officers to examine
any bank account established in connection with this business, and to examine and
secure copies of any business records or documents established in connection with the
business including, but not limited to, those on file with my bookkeeper or with the above
named bank(s). I also have read all the above and declare under penalty of perjury that
each and every statement is true and correct.
Signature: ______________________
Date: __________________________
Witness: _______________________

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