Form At-212 - Application For Vessel Permit - Wisconsin Department Of Revenue Page 3
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4AUXILIARY QUESTIONNAIRE
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
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 resided in Wisconsin continuously for 90 days prior to the
5. Have you resided in Wisconsin continuously for 90 days prior to the
date of this application?
Yes
No
date of this application?
Yes
No
6. Have you ever been convicted of violating any federal law?
6. 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.)
7. Are you an officer, director, agent or employe of any person or corpo
7. Are you an officer, director, agent or employe of any person or corpo
ration holding or applying for any other license or permit to sell
ration holding or applying for any other license or permit to sell
alcohol beverages in Wisconsin?
Yes
No
alcohol beverages in Wisconsin?
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
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 resided in Wisconsin continuously for 90 days prior to the
5. Have you resided in Wisconsin continuously for 90 days prior to the
date of this application?
Yes
No
date of this application?
Yes
No
6. Have you ever been convicted of violating any federal law?
6. 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.)
7. Are you an officer, director, agent or employe of any person or corpo
7. Are you an officer, director, agent or employe of any person or corpo
ration holding or applying for any other license or permit to sell
ration holding or applying for any other license or permit to sell
alcohol beverages in Wisconsin?
Yes
No
alcohol beverages in Wisconsin?
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
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