Form 926 - Operator'S License Application - Village Of Brown Deer, Wisconsin
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1
2OPERATOR’S LICENSE APPLICATION
VILLAGE OF BROWN DEER, WISCONSIN 53223
DATE:__________________________
Name of Establishment Where This License Will Be Used?___________________________________________
FEE: $50.00 for 2-Year License
RECEIPT NO._________________
Plus $20.00 for Police Department Background Check
.
**IF APPLICATION IS DENIED OR APPLICANT WITHDRAWS, ALL FEES ARE NON-REFUNDABLE
PROCESS TIME: 7-10 WORKING DAYS
APPLICANT MUST BE 18 YEARS OF AGE OR OLDER TO APPLY.
Read instructions and notice on reverse side of this application before completing items below. Answer all questions and
supply all information requested. PRINT CLEARLY.
1.
Name_______________________________________________________________________________________
first
middle initial
last
(maiden name)
2.
Permanent Address:___________________________________________________________________________
City/State/Zip:________________________________________________________________________________
Telephone:(
)_________________________________________________________________________
Driver=s License No.:___________________________________________________________________________
*Social Security No.:__________________-_____________-__________________
3.
List Previous Addresses for past five (5) Years (If None, Write ANone@)
Address
Date Last Lived There
________________________________________________________
___________________________
________________________________________________________
___________________________
4.
Date of Birth:________/________/________
Sex:_____________
Race:__________________
5.
Do You Now Hold or Have You Ever Been Granted Any License or Permit Associated with the Sale of
Alcoholic Beverages? (
)Yes (
) No
If Yes, list type of license, dates held, and issuing jurisdiction:
Date
Type of License
Issued By
____________________
__________________________ __________________________________
____________________
__________________________ __________________________________
6.
Have You Ever, In Your Lifetime, Been Convicted of Violating Any Law, Ordinance or Regulation Pertaining
to the Sale of Alcoholic Beverages? (
)Yes (
) No
If Yes, list date(s), violation, and jurisdiction:
Date
Type of License
Issued By
____________________
_________________________
__________________________________
____________________
_________________________
__________________________________
FORM 926 (REV 01/2012)
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Parent category: Business