Application For Transfer In Officers/stock Of Alcoholic Beverage Retailers Permit Page 3
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6Form 1001 (11/95)
PERSONAL RECORD
ALCOHOLIC BEVERAGE CONTROL
PERMIT DEPARTMENT
P.O. BOX 540, MADISON, MS. 39130-0540
1.
Name _____________________________________________________
(last)
(first)
(middle)
_
sole owner _
partner _
officer _
stockholder _
manager
2.
Name of business ____________________________________________
3.
Date of Birth ________________ Social Security No. _______________
Driver’s License No. _____________________ Age _______ Sex _____
Height ____________ Weight ____________ Hair color ____________
Eye color __________ Race ___________
4.
Telephone No.
________________
_________________
(home)
(business)
5.
List your residences for the past five years, starting with current address.
FROM
TO
ADDRESS
CITY, STATE, ZIP CODE
MO./YR.
MO./YR.
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
6.
List your employment or occupational history for the past five (5) years.
FROM
TO
EMPLOYER
CITY, STATE
MO./YR.
MO./YR.
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
________ ________
_____________________________________
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