Questionnaire - Arizona Department Of Liquor Licenses And Control - 2015
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1
2State of Arizona
Department of Liquor Licenses and Control
800 W. Washington 5
Floor
th
Phoenix, AZ 85007
(602) 542-5141
QUESTIONNAIRE
Attention local governments: Social security and birth date information is confidential. This information may be given to law enforcement
agencies for the purpose of background checks only.
Attention applicant: This is a sworn document. Type or print in black ink. An extensive investigation of your background will be conducted. False
or incomplete answers could result in criminal prosecution and the denial or the subsequent revocation of a license or permit.
QUESTIONNAIRE TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER. EACH PERSON COMPLETING THIS FORM MUST SUBMIT
AN “APPLICANT” TYPE FINGERPRINT CARD AVAILABLE AT THIS OFFICE FINGERPRINTS ON FBI APPROVED CARDS (BLUE LINED) ARE ACCEPTED FROM
LAW ENFORCEMENT AGENCIES, BONA FIDE FINGERPRINT SERVICES OR THE DEPARTMENT OF LIQUOR. THE DEPARTMENT OF LIQUOR CHARGES A $13
FEE. IN ADDITION TO OTHER FINGERPRINT FEES, A $22.00 DPS BACKGROUND CHECK FEE WILL BE CHARGED FOR EACH FINGERPRINT CARD.
The fees allowed by A.R.S. § 4-6852 will be charged for all dishonored checks.
Liquor License#:
(If the location is currently licensed)
1.Check the
Controlling Person
Agent
Manager
appropriate
box
(complete questions 1-19)
(complete all questions except #14, 14a & 21,
Controlling Person or Agent must complete #21)
2. Name: _____________________________________________________________________________________ Birth Date: _____/_____/______
Last
First
Middle
(NOT a public record)
3. Social Security #: ____________________________ Driver License#: _______________________________ State: ______________________
(NOT a public record)
4. Place of birth: _______________________________________________ Height: ________ Weight: ________ Eyes: ________ Hair: _______
City
State
COUNTRY (not county)
5. Marital status:
Single
Married
Divorced
Widowed
6. Name of current/most recent spouse: _________________________________________________________ Birth Date: _____/_____/_____
(List all for past 5-years, use additional sheet if necessary)
Last
First
Middle
Maiden
(NOT a public record)
7. You are a bona fide resident of what state? _____________________ ___ If Arizona, date of residency: __________________________
If you have been an Arizona resident for less than three (3) months, submit a copy of your Arizona Drivers license or voters
registration card.
8. Daytime telephone number to contact you during business hours for questions: _____________________________________________
9. E-mail address: ___________________________________________________________________________________________________________
10. Business Name: ________________________________________________________________________ Business Phone: _____/_____/______
11. Business Location Address: _______________________________________________________________________________________________
Street (do not use P O box#)
City
State
County
Zip
12. List your employment or type of business during the past five (5) years. If unemployed, retired, student list residence address.
FROM
TO
EMPLOYERS NAME OR NAME OF BUSINESS
DESCRIBE POSITION OR BUSINESS
Month/Year
Month/Year
(Street Address, City, State & Zip)
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
13. Indicate your residence address for the last five (5) years:
RESIDENTIAL Street Address
FROM
TO
Rent or
(IF RENTED ATTACH ADDITIONAL SHEET WITH, NAME ADDRESS, AND
City
State
Zip
Month/Year
Month/Year
Own
PHONE NUMBER OF LANDLORD)
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
10/26/2015
Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-9027
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