Form Ab-115 - Wisconsin Liquor/wine Permit Application Page 5
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8AUXILIARY QUESTIONNAIRE
Each individual, partner, member, and corporate officer, director, and agent must complete, attach all questionnaires to this ap-
plication before submitting.
Name of Individual, Partner, Member, Officer, etc.
Date of Birth
Social Security Number
Home Address
City
State
Zip Code
Telephone Number
(
)
YES
NO
Have you resided in Wisconsin for at least 90 continuous days prior to the date of filing this application?
YES
NO
Have you applied for, or do you possess or hold any interest directly or indirectly in, a Wisconsin retail license
to sell intoxicating liquor?
YES
NO
Are you a member of any Wisconsin town or village board or common council of any municipality?
If YES, identify
Town
Village
City
of
name of municipality
YES
NO
Have you ever been convicted of violating federal or state laws or local ordinances other than traffic violations?
If YES, check type violated
Federal
State
Local Ordinances
Indicate details of the violation (nature, date, place, court, and disposition):
If you have been convicted of a felony for which you received a pardon, specify nature of felony, date, and place of pardon.
I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Date
Your Signature
Wisconsin Department of Revenue
AUXILIARY QUESTIONNAIRE
Each individual, partner, member, and corporate officer, director, and agent must complete, attach all questionnaires to this ap-
plication before submitting.
Name of Individual, Partner, Member, Officer, etc.
Date of Birth
Social Security Number
Home Address
City
State
Zip Code
Telephone Number
(
)
YES
NO
Have you resided in Wisconsin for at least 90 continuous days prior to the date of filing this application?
YES
NO
Have you applied for, or do you possess or hold any interest directly or indirectly in, a Wisconsin retail license
to sell intoxicating liquor?
YES
NO
Are you a member of any Wisconsin town or village board or common council of any municipality?
If YES, identify
Town
Village
City
of
name of municipality
YES
NO
Have you ever been convicted of violating federal or state laws or local ordinances other than traffic violations?
If YES, check type violated
Federal
State
Local Ordinances
Indicate details of the violation (nature, date, place, court, and disposition):
If you have been convicted of a felony for which you received a pardon, specify nature of felony, date, and place of pardon.
I declare under penalties of the law that I have examined this information and, to the best of my knowledge, it is true, correct, and complete.
Date
Your Signature
AB-115
Wisconsin Department of Revenue
-5-
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