Applicant/controlling Person Affidavit - Arizona Department Of Liquor Licenses And Control
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1
2Arizona Department of Liquor Licenses and Control
800 W Washington 5th Floor
Phoenix, AZ 85007-2934
(602) 542-5141
APPLICANT/CONTROLLING PERSON AFFIDAVIT
TO BE COMPLETED BY THE ORGANIZATION'S PRESIDENT.
IF THIS IS A CLUB, PARTNERSHIP, OR OTHER TYPE OFORGANIZATION, A SIGNATURE OF EQUAL LEVEL IS REQUIRED.
Organization:
Affidavit of:
Position/Title:
State of:
AZ Corp./L.L.C. #:
County of:
State Incorporated:
The undersigned,
Being first sworn under oath declares:
1.
In connection with this organization's application to obtain a liquor license for our operation(s) in Arizona,
have complete d and delivered to the Arizona Department of Liquor Licenses and Control the required
questionnaire and fingerprint card
2.
The required questionnaires and fingerprint cards of all officers, directors, regional managers, managing
members, partners, etc., who direct or are involved in the direction of the management of the policies
involving spirituous liquor in the State of Arizona; and all stockholders who own ten percent (10%) or more
of the corporation or limited liability company have also been completed and delivered to the Arizona
Department of Liquor Licenses and Control.
Name and title of such individuals are as follows (or list attached):
1)
2)
3)
4)
11/18/2015
Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-9027
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