Form At-105 - Application For Airport/public Facility Permit Page 3
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4AUXILIARY QUESTIONNAIRE
To be completed by each individual, partner, or member and each officer, director, and agent applying for a permit to sell alcohol beverages.
1. Name
1. Name
(print or type)
Last
First
M.I.
(print or type)
Last
First
M.I.
2. Title
2. Title
3. Business or occupation for past three years:
3. Business or occupation for past three years:
4. Date of Birth
Place of Birth
4. Date of Birth
Place of Birth
5. Have you ever been convicted of violating any federal law?
5. Have you ever been convicted of violating any federal law?
Yes
No; state law
Yes
No
Yes
No; state law
Yes
No
Any municipal ordinance?
Yes
No
Any municipal ordinance?
Yes
No
(Attach explanation of any Yes answer.)
(Attach explanation of any Yes answer.)
6. Are you an officer, director, agent or employe of any person, member
6. Are you an officer, director, agent or employe of any person, member
of Limited Liability Company, or corpo ration holding or applying for any
of Limited Liability Company or corpo ration holding or applying for any
other license or permit to sell alcohol beverages in Wisconsin?
other license or permit to sell alcohol beverages in Wisconsin?
Yes
No
Yes
No
(If Yes, identify by name of licensee or permittee, class of license or
(If Yes, identify by name of licensee or permittee, class of license or
permit, and municipality.)
permit, and municipality.)
I declare under the penalties of law that I have examined this information
I declare under the penalties of law that I have examined this information
and to the best of my knowledge, it is true, correct, and complete.
and to the best of my knowledge, it is true, correct, and complete.
Your Signature
Date
Your Signature
Date
1. Name
1. Name
(print or type)
(print or type)
Last
First
M.I.
Last
First
M.I.
2. Title
2. Title
3. Business or occupation for past three years:
3. Business or occupation for past three years:
4. Date of Birth
Place of Birth
4. Date of Birth
Place of Birth
5. Have you ever been convicted of violating any federal law?
5. Have you ever been convicted of violating any federal law?
Yes
No; state law
Yes
No
Yes
No; state law
Yes
No
Any municipal ordinance?
Yes
No
Any municipal ordinance?
Yes
No
(Attach explanation of any Yes answer.)
(Attach explanation of any Yes answer.)
6. Are you an officer, director, agent or employe of any person, member
6. Are you an officer, director, agent or employe of any person, member
of Limited Liability Company, or corpo ration holding or applying for any
of Limited Liability Company or corpo ration holding or applying for any
other license or permit to sell alcohol beverages in Wisconsin?
other license or permit to sell alcohol beverages in Wisconsin?
Yes
No
Yes
No
(If Yes, identify by name of licensee or permittee, class of license or
(If Yes, identify by name of licensee or permittee, class of license or
permit, and municipality.)
permit, and municipality.)
I declare under the penalties of law that I have examined this information
I declare under the penalites of law that I have examined this information
and to the best of my knowledge, it is true, correct, and complete.
and to the best of my knowledge, it is true, correct, and complete.
Your Signature
Date
Your Signature
Date
**THIS FORM MAY BE REPRODUCED**
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