Form Ab-121 - Liquor / Wine Salesperson'S Permit Application
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1
2DEPARTMENT USE ONLY
AB-121: Liquor / Wine Salesperson’s
Permit Number
Permit Application
Period Covered
Date of Issuance
Read instructions before completing.
Last Name (please print)
First
M.I.
Date of Birth (MM-DD-YYYY)
Home Address
Social Security Number
City or Post Office
State
Zip Code
Phone Number
1. Current Business or Occupation (be specific)
2. Business or Occupation for the past three years.
3. Have you individually, or have you as a Sole Proprietor, Partner(s), Limited Liability Company Member(s), or Corporate
Officer(s), ever held, or now hold, a permit or certificate issued by the Wisconsin Department of Revenue?
YES
NO
If YES, indicate type, number, and location for which it was issued.
4. Have you, your spouse, or member of your household made, or are making, application for, or have any
direct or indirect interest in, a retail liquor/wine license in Wisconsin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If YES, indicate the date, municipality involved, and the type of liquor license.
5. Are you a member of any Wisconsin town board, village board, or common council of any municipality?
YES
NO
If YES, identify
Town
Village
City
of
name of municipality
6. Have you ever been convicted of violating federal or state laws or local ordinances other than traffic violations?
YES
NO
If Yes, check type of law violated:
Federal
State
Local Ordinances
Details of the violation, including nature of violation, date, place, court, and disposition:
If you have been convicted of a felony for which you received a pardon, describe the nature of the felony and date/place of the pardon.
Name of Permittee Which Applicant Will Represent
Permit #
Address
City
State
Zip Code
I declare under penalties of law that I have examined this information and to the best of my knowledge it is true, correct, and complete.
Date
Your Signature
AB-121 (R. 12-13)
See reverse side for Instructions.
Wisconsin Department of Revenue
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Parent category: Financial