Affidavit Form - City Of Independence, Missouri Finance Department (Page 4 of 4) in pdf

Affidavit Form - City Of Independence, Missouri Finance Department Page 4

by any person, partnership, LLC, or corporation that had a license revoked or suspended by the Supervisor of Liquor

Control?

If so, give details

31.

State the name and residence of each person, firm, LLC, or corporation, if any, other than the corporation and

its stockholders, or the LLC and its members, interested, or to become interested, directly or indirectly, other than

herein above set out, in the business for which a license is sought and the nature of such interest

32.

Is this application being made by the corporation or the LLC to permit any person other than yourself to obtain a license

from the Missouri Supervisor of Liquor Control, in your name, for his or her benefit?

I, or we, (please print)

(owner, all partners, or Managing Officer)

being of lawful age and duly sworn upon my/our oath do swear that the answers and information given in this application are

true and complete to the best of my/our knowledge and belief.

Subscribed and sworn to before me, a Notary Public, this

day of

, 20

Notary Public

My Commission expires:

Affidavit Form - City Of Independence, Missouri Finance Department Page 4