Form Abc-208-A Individual Personal Affidavit - Department Of Alcoholic Beverage Control
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1Limited Partner
Department of Alcoholic Beverage Control
State of California
Edmund G. Brown Jr., Governor
INDIVIDUAL PERSONAL AFFIDAVIT
Instructions: This form must be completed by: sole owners and their spouses; each general partner
and their spouses; officers of a corporation and a majority of the board of directors; persons holding
10% or more of the capital or stock of a corporation and their spouses; persons holding 10% or more
FINGERPRINTING (ABC USE ONLY)
of the capital or stock of a limited liability company or limited partnership and their spouses.
Active
Livescan
Date:
If Item #23b is checked, you must complete Form ABC-208-B, Financial Affidavit.
1. FIRST NAME
MIDDLE NAME
LAST NAME
2. PREVIOUS NAME(S) (Include maiden name, aka, alias)
3. PREMISES ADDRESS
4. PREMISES TELEPHONE NUMBER
5. HOME ADDRESS
6. HOME TELEPHONE NUMBER
7. SOCIAL SECURITY NUMBER
8. DRIVER'S LICENSE OR ID NUMBER
9. STATE WHERE DL OR ID ISSUED
10. WORK OR CELL TELEPHONE NUMBER
11. PERSONAL DATA
HEIGHT
WEIGHT
EYE COLOR
HAIR COLOR
Male
Female
12. BIRTHDATE
13. BIRTHPLACE (City, State, Country)
14. MARITAL STATUS
Single
Divorced
Widow(er)
Married
Separated
Registered Partner
15. SPOUSE'S/REGISTERED PARTNER'S NAME (Last, first, middle) (Include alias)
16. MARRIAGE DATE
17. MARRIAGE PLACE (City, State)
18. I AM OR WILL BE
Sole Owner
General Partner
Food Lessee
Officer
Title:
Spouse/Registered Partner
Limited Partner
Director
LLC Member/Managing Member
Partner
Manager
Stockholder
19. Do you now have any direct, or indirect, interest in any other alcoholic beverage business, or have you ever been an alcoholic
beverage licensee or an officer or director of a corporate licensee in or outside of California?
Yes
No
IF YES, EXPLAIN (List License number and/or premises address)
20. Have you as an individual, a partner, or while an officer, director, or stockholder of a corporation ever had an alcoholic
beverage license denied, suspended, revoked, or an offer in compromise accepted or rejected?
Yes
No
IF YES, EXPLAIN
21. EMPLOYMENT HISTORY (Past five years - include unemployed, student, homemaker, etc. Use additional sheets if needed.)
FROM (MONTH/YEAR)
TO (MONTH/YEAR)
JOB TITLE
COMPANY NAME AND CITY
22. Have you ever, anywhere or at any time, (1) forfeited bail, (2) been convicted, (3) fined, or (4) placed on probation for any
violation of the law? (5) Are you now actively being prosecuted for a criminal offense?
(If any of these events has occurred, this question must be answered "Yes" regardless of subsequent court action resulting in
expungement, unless an order sealing records under Section 1203.45 of the Penal Code, relating to persons under age 18 years,
Yes
No
has been issued. If no order has been issued, the answer must be "Yes.")
ARREST DATE
PLACE OF ARREST
OFFENSE
RESULT/DISPOSITION
23. FINANCIAL CONTRIBUTION TO THE BUSINESS (If Box B is checked, complete Form ABC-208-B)
A. I am not making a contribution in any form
C. I am contributing labor/expertise only
B. I am making a financial contribution
D. Same as the affidavit of
I have read all of the above and declare under penalty of perjury that each and every statement
is true, correct and complete.
AFFIANT SIGNATURE
TITLE
DATE SIGNED
PLACE SIGNED
ATTEST (ABC EMPLOYEE OR NOTARY PUBLIC)
ABC-208-A (rev. 06-13)
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