Questionnaire - Arizona Department Of Liquor Licenses And Control Page 2
Download a blank fillable Questionnaire - Arizona Department Of Liquor Licenses And Control in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Questionnaire - Arizona Department Of Liquor Licenses And Control with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2A.R.S. §4-202(D)
11. Provide your residence address information for the last five (5) years:
FROM
TO
RESIDENTIAL Street Address
Month/Year
Month/Year
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises?
Yes
No
If you answered YES, then answer #13 below. If NO, skip to #14.
13. Have you attended a DLLC approved Basic & Management Liquor Law Training Course within the past 3
Yes
No
years?
14. Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal
Yes
No
law or ordinance, regardless of the disposition, even if dismissed or expunged, within the past five (5) years?
15. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or
Yes
No
A.R.S.§4-202,4-210
summonses pending against you? (Do not include civil traffic tickets.)
16. Has anyone EVER obtained a judgement against you the subject of which involved fraud or misrepresentation?
Yes
No
17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizona
Yes
No
A.R.S.§4-202(D)
within the last five years?
Yes
No
18. Has an entity in which you are or have been a controlling person had an application or license rejected,
A.R.S.§4-202(D)
denied, revoked or suspended in or outside of Arizona within the last five years?
If you answered “YES” to any Question 14 through 18 YOU MUST attach a signed statement.
Give complete details including dates, agencies involved and dispositions.
CHANGES TO QUESTIONS 14-18 MAY NOT BE ACCEPTED
NOTARY
I
______________________________________________ hereby declare that I am the Agent/ Controlling Person /
(Print Full Name)
Premises Manager filing this application. I have read this document and verify the contents and all statements are true,
correct and complete, to the best of my knowledge.
Signature: ___________________________________________
State of _________________ County of _______________________
The foregoing instrument was acknowledged before me this
My Commission Expires on: ___________________________
___________ Day of _____________________, ___________
Date
Day
Month
Year
___________________________________________________
Signature of Notary
The Licensee has authorized the person named on this questionnaire to act as manager for the above License.
PRINT NAME
SIGNATURE:
: _______________________________________________________________
_______________________________________________________________
1/11/2018
Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999
ADVERTISEMENT
0 votes
Related Articles
Related forms
License Application Instructions And Requirements - Arizona Department Of Liquor Licenses And Control
Legal
Instructions For Arizona Liquor License Renewal - Arizona Department Of Liquor Licenses And Control
Legal
How To Read A Liquor License And What The Numbers Mean - Arizona Department Of Liquor Licenses And Control
Legal
Application For Out-of-state Producer Liquor Licenses- Arizona Department Of Liquor Licenses And Control
Legal
Application For Growler Privileges With Series 12 Liquor License - Arizona Department Of Liquor Licenses And Control
Legal
Related Categories
Parent category: Legal