Form Dr 8404-I - Individual History Record - Colorado Department Of Revenue
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2DR 8404-I (03/13/15)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Individual History Record
To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and
limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any
stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company,
and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant or Tavern class of
retail license
Notice: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions
must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate
so by “N/A”. Any deliberate misrepresentation or material omission may jeopardize the license application. (Please attach a
separate sheet if necessary to enable you to answer questions completely)
1. Name of Business
Home Phone Number
Cellular Number
2. Your Full Name (last, first, middle)
3. List any other names you have used
4. Mailing address (if different from residence)
Email Address
5. List current residence address. Include any previous addresses within the last five years. (Attach separate sheet if necessary)
Street and Number
City, State, Zip
From
To
Current
Previous
6. List all employment within the last five years. Include any self-employment. (Attach separate sheet if necessary)
Name of Employer or Business
Address (Street, Number, City, State, Zip)
Position Held
From
To
7. List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry.
Name of Relative
Relationship to You
Position Held
Name of Licensee
8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money,
Yes
No
furniture, fixtures, equipment or inventory to any licensee? (If yes, answer in detail.)
9. Have you ever received a violation notice, suspension, or revocation for a liquor law violation, or have you
Yes
No
applied for or been denied a liquor or beer license anywhere in the United States? (If yes, explain in detail.)
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