Questionnaire - Arizona Department Of Liquor Licenses And Control

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Arizona Department of Liquor Licenses and Control
800 W Washington 5
Floor
th
Phoenix, AZ 85007-2934
(602) 542-5141
QUESTIONNAIRE
A.R.S.§4-202, 4-210
Type or Print with Black Ink
The fees allowed by R19-1-102 will be charged for all dishonored checks.
ATTENTI0N APPLICANT: This is a legally binding document. Please type or print in black ink. An investigation of your
background will be conducted. Incomplete applications will not be accepted. False or misleading answers may result in the
denial or revocation of a license or permit and could result in criminal prosecution.
Attention local governments: Social security and birth date information is confidential. This information may be given to law
enforcement agencies for background checks only.
QUESTIONNAIRE IS TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER BEING DISCLOSED TO THE DEPARTMENT. EACH
PERSON COMPLETING THIS FORM MUST SUBMIT A BLUE OR BLACK LINED FINGERPRINT CARD ALONG WITH A $22 FEE. FINGERPRINTS MUST BE DONE
BY A LAW ENFORCEMENT AGENCY OR BONA FIDE FINGERPRINT SERVICE. FOR AN ADDITIONAL $13 FEE, FINGERPRINTS MAY BE DONE AT THE
DEPARTMENT OF LIQUOR WHEN ACCOMPANIED BY A COMPLETED APPLICATION.
Liquor License#:
1. Check the
Appropriate
Box
Controlling Person
Agent
Premises Manager
(complete all questions except #12)
2. Name: _____________________________________________________________________________________ Birth Date:_____/_____/______
Last
First
Middle
(NOT a public record)
3. Social Security #: ____________________________ Driver License#: ______________________________ State: ______________________
4. Place of birth: ______________________________________________ Height: ________ Weight: ________ Eyes: _______ Hair: ________
City
State
COUNTRY (not county)
5. Name of current/most recent spouse: ________________________________________________________ Birth Date: _____/_____/_____
Last
First
Middle
(NOT a public record)

Yes
No
6. Are you a bona fide resident of Arizona?
If yes, what is your date of residency: _____________________________
7. Daytime telephone number: ____________________________ E-mail address: _________________________________________________
8. Business Name: ______________________________________________________________________ Business Phone: _____/______/______
9. Business Location Address: ______________________________________________________________________________________________
Street (do not use PO Box )
City
State
County
Zip
10. List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.
FROM
TO
EMPLOYERS NAME OR NAME OF BUSINESS
DESCRIBE POSITION OR BUSINESS
Month/Year
Month/Year
(Street Address, City, State & Zip)
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
1/11/2018
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Individuals requiring ADA accommodations please call (602)542-2999

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