Plcb-196 - Individual Questionnaire For Officers, Directors, Stockholders, Business Trustees, Limited Liability Company Member, Limited Or General Partners

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PLCB-196  3/09    I
INDIVIDUAL QUESTIONNAIRE FOR OFFICERS,
DIRECTORS, STOCKHOLDERS, BUSINESS
COMMONWEALTH  OF  PENNSYLVANIA
BUREAU  OF  LICENSING
TRUSTEES, LIMITED LIABILITY COMPANY
PENNSYLVANIA
MEMBER, LIMITED OR GENERAL PARTNERS
LIQUOR  CONTROL  BOARD
(SEE  REVERSE)
1.  NAME  OF  LICENSEE/APPLICANT
LICENSE  NO.
LID  NO.
2.  ADDRESS
3.  NAME  OF  ENTITY
4.  ADDRESS
5.  NAME  OF  INDIVIDUAL
6.  HOME  ADDRESS
7.  U.S.  CITIZEN
DATE  OF  BIRTH
PLACE  OF  BIRTH
YES
NO
IF  NATURALIZED,  GIVE  DATE,  PLACE  AND  CERTIFICATE  NO.
IF  LAWFUL  ALIEN,  ALIEN  ID  NO.
8.  CURRENT  EMPLOYMENT
DATES
ADDRESS
NAME  OF  EMPLOYER
FROM
TO
PRESENT
(a) Type of business
CONVICTION RECORD: The following is a record of all felony and misdemeanor convictions of the individual, officer, director or stockholder.
9.
(Attach separate sheet if necessary.) If there have been no such convictions,  insert the word “NONE.”
LOCATION  OF  COURT
DATE  OF
CHARGE
NAME
DISPOSITION
(COUNTY  AND  STATE)
CONVICTION
10.  ARE  YOU  OR  YOUR  SPOUSE: 
SPOUSE’S  NAME
YES
NO
(a) A director, officer, stockholder or creditor of any other Pennsylvania licensee or manufacturer (any entity
involved in producing, manufacturing, distilling, rectifying or compounding liquor, alcohol, or malt or brewed
beverage?
(b) The owner, proprietor or lessor of any place licensed by the PLCB or in the equipment used by same?
(c) Financially interested, either directly or indirectly, in the profits of any other business licensed by the PLCB or
have any financial interest or connection with the same? (i.e. loans, mortgages)
(d) The holder of any license issued by the PLCB?
(e) A public official involved in the enforcement of penal laws, either by appointment or election?
(f) The employee of any licensee?
(g) If any "yes" answers to (a) through (f) apply to your spouse, are funds involved in this transaction held jointly?
(h) Comment on any "yes" replies to (a) through (g):
11. WILL YOU BE ACTIVELY ENGAGED IN THIS BUSINESS?
YES
NO
IF  YES,  GIVE  DETAILS
I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §4-403(h) and/or §4-436(j) and/or §5-504(b) and/or  
§7-704, that the foregoing answers and statements provided herein are true and complete to the best of my knowledge and belief.
SIGNATURE
TITLE
DATE

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