Applicant/controlling Person Affidavit - Arizona Department Of Liquor Licenses And Control Page 2
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23.
There are, in addition to those submitting questionnaires and fingerprint cards, other officers, limited
liability members, and/or board members of this organization who are not submitting such information to
the Arizona Department of Liquor Licenses and Control. None of these individuals directs or is involved in
the direction of the management of policies of this organization involving spirituous liquor in the State of
Arizona
.
Such members and positions, along with date and place of birth, are as follows (or list attached):
1)
2)
3)
4)
4.
None of the individuals listed under item #3 possesses the power to vote ten percent (10%) of the
outstanding voting securities of this organization, nor can any of them control the election of one or
more of the Board of Directors or managing members of the organization.
5.
Finally, on information and belief, none of the individuals listed under item #3 have at any time been
convicted of a felony, had a liquor license revoked, or violated any provisions of a liquor license issued
to that member.
DATED this _________ day of ________________________, ____________
Day
Month
Year
I,
__________________________________________________declare that I am the APPLICANT filing this notification.
(Print Full Name)
I have read this document and the contents and all statements are true, correct and complete
.
X
(Signature) ____________________________________________________________________________
State _______________________ County of ______________________
The foregoing instrument was acknowledged before me this
_________day of ___________________________, __________________
Day
Month
Year
My Commission Expires on: ___________________
______________________________________________________________
Date
(Signature of Notary Public)
11/18/2015
Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-9027
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