Form Dr 8404-I - Individual History Record - Colorado Department Of Revenue Page 2
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210. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited
Yes
No
bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.)
11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a
Yes
No
deferred sentence? (If yes, explain in detail.)
12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.)
Yes
No
Personal and Financial Information
Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal
information required in question #13 is solely for identification purposes.
13a. Date of Birth
b. Social Security Number
c. Place of Birth
Yes
No
d. U.S. Citizen
e. If Naturalized, state where
f. When
g. Name of District Court
h. Naturalization Certificate Number i. Date of Certification j. If an Alien, Give Alien’s Registration Card Number k. Permanent Residence Card Number
l. Height
m. Weight n. Hair Color
o. Eye Color p. Gender
q. Race
r. Do you have a current Driver’s License/ID? If so, give number and state.
Yes
No # __________________ State _________________
14. Financial Information.
a. Total purchase price or investment being made by the applying entity, corporation, partnership, limited liability company, other.
$ _________________________________
b. List the total amount of the personal investment , made by the person listed on question #2, in this business including any
notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid. $ __________________________
* If corporate investment only please skip to and complete section (d)
** Section b should reflect the total of sections c and e
c. Provide details of the personal investment described in 14b. You must account for all of the sources of this investment.
(Attach a separate sheet if needed)
Type: Cash, Services or Equipment
Account Type
Bank Name
Amount
d. Provide details of the corporate investment described in 14 b. You must account for all of the sources of this investment. (Attach a
separate sheet if needed)
Type: Cash, Services or Equipment
Loans
Account Type
Bank Name
Amount
e. Loan Information (Attach copies of all notes or loans)
Name of Lender
Address
Term
Security
Amount
Oath of Applicant
I declare under penalty of perjury that this application and all attachments are true, correct, and complete to the best of my knowledge.
Authorized Signature
Print Signature
Title
Date
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Parent category: Financial