Beneficial Interest Contact - Individual
Download a blank fillable Beneficial Interest Contact - Individual in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Beneficial Interest Contact - Individual with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ALCOHOLIC BEVERAGES CONTROL COMMISSION
BENEFICIAL INTEREST CONTACT - Individual
(Formerly known as a Personal Information Form)
Please complete a Beneficial Interest - Individual sheet for all individual(s) who have a direct or indirect beneficial interest, with
or without ownership, in this license. This includes people with a financial interest and people without financial interest (i.e.
board of directors for not-for-profit clubs). All individuals with direct or indirect financial interest must also submit a
CORI
Authorization
Form.
An individual with direct beneficial interest is defined as someone who has interest directly in the proposed licensee. For
example, if ABC Inc is the proposed licensee, all individuals with interest in ABC Inc are considered to have direct beneficial
interest in ABC Inc (the proposed licensee).
An individual with indirect beneficial interest is defined as someone who has ownership in a parent level company of the
proposed licensee. For example, if ABC Inc is the proposed licensee and is 100% owned by XYZ Inc, all individuals with interest
in XYZ Inc are considered to have an indirect beneficial interest in ABC Inc (the proposed licensee).
Salutation
First Name
Middle Name
Last Name
Suffix
Social Security Number
Title:
Date of Birth
Primary Phone:
Email:
Mobile Phone:
Fax Number
Alternative Phone:
Business Address
Street Number:
Street Name:
City/Town:
State:
Zip Code:
Country:
Mailing Address
Check here if your Mailing Address is the same as your Business Address
Street Number:
Street Name:
City/Town:
State:
Zip Code:
Country:
Types of Interest (select all that apply)
Contractual
Director
Landlord
LLC Manager
Management Agreement
LLC Member
Officer
Partner
Revenue Sharing
Sole Proprietor
Stockholder
Other
Citizenship / Residency Information
Are you a U.S. Citizen?
Are you a Massachusetts Resident?
Yes
No
Yes
No
Criminal History
Have you ever been convicted of a state, federal, or military crime?
If yes, please provide an affidavit
Yes
No
explaining the charges.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal