Personal History Information Form - Alcoholic Beverage Control Board
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1
2ALCOHOLIC BEVERAGE CONTROL BOARD
550 W 7TH AVENUE
ANCHORAGE, ALASKA 99501
(907) 277-8638
PERSONAL HISTORY INFORMATION
Side 1
Name (Last, First, Middle, Maiden/all other previously used names)
Driver's License No.
State:
Date of Birth
Social Security Number:
Name of Business
Location:
City:
Sex
Race
Weight
Height
Eye Color
Place of Birth
Name of Spouse:
EMPLOYMENT HISTORY
RESIDENCE HISTORY
List all places of employment for past ten (10) years
List all places of residence
If self-employed, list particulars. If unemployed or
for past ten (10) years.
attending school, so indicate.
Use additional sheet if necessary
Use additional sheet if necessary.
EMPLOYMENT HISTORY
RESIDENCE HISTORY
From-To
Your Title, Employer, Address (City, Country, State)
From-To
Residence Address (City, Country, State)
NOW GO TO SIDE (2) TO PROVIDE CRIMINAL HISTORY INFORMATION AND CERTIFICATION:
* You are not required to provide your social security number, but the information is requested based on
AS 04.11.260 and 15 AAC 104.105(b) for identification purposes for the Alcoholic Beverage Control Board's use only.
Requires Further Action
Office
Use
APSIN DATE:
[
] Yes
[
] No
Only
Investigator's Comment:
Investigator:
Date:
Report No.:
REV. 1/20/95/history.xls
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