Form Dbpr Abt-6008 - Application For Importer Or Broker Sales Agent Page 2
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7SECTION 4 – PARTNER, OFFICER, STOCKHOLDER PERSONAL INFORMATION
This section must be completed for each applicant or person(s) directly connected with the business,
unless they are current licensees.
1.
Trade Name (D/B/A)
2.
Full Name of Applicant
Social Security Number*
Home Phone Number
Date of Birth
Race
Sex
Height
Weight
Eye Color
Hair Color
3.
Are you a U.S. citizen?
1. Yes
No
If no, immigration card number or passport number:
4.
Home Address (Street and Number)
City
State
Zip Code
5.
Do you currently own or have an interest in any business selling alcoholic beverages, wholesale
cigarette or tobacco products, or a bottle club?
Yes
No
If yes, provide the information requested below. The location address should include city and state.
Trade Name (D/B/A)
License Number
Location Address
6.
Have you ever had any type of alcoholic beverage, or bottle club license, or cigarette, or tobacco permit
refused, revoked or suspended anywhere in the past 15 years?
Yes
No
If yes, provide the information requested below. The location address should include the city and state.
D/B/A Name
Date
Location Address
7.
Have you been convicted of a felony or an offense involving alcoholic beverages anywhere?
Yes
No
If yes, provide the information requested below and provide a Certified Copy of the Arrest
Disposition, as requested in the Application Requirements checklist.
Date
Location
Type of Offense
8.
Have you ever been arrested or issued a notice to appear in any state of the United States or its
territories?
Yes
No
If yes, provide the information requested below and a CERTIFIED COPY OF THE DISPOSITION.
Attach additional sheet if necessary.
Date
Location
Type of Offense
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