Auxiliary Questionnaire
Alcohol Beverage License Application
AT-103 (R. 7-18) Wisconsin Department of Revenue
Submit to municipal clerk.
(Signature of Named Individual)
Home Phone Number Age Date of Birth Place of Birth
Home Address (street/route) PostOce City State ZipCode
Individual's Full Name (please print) (last name) (rst name) (middle name)
The above named individual provides the following information as a person who is (check one):
Applyingforanalcoholbeveragelicenseasanindividual.
A member of a partnership which is making application for an alcohol beverage license.
of
which is making application for an alcohol beverage license.
The above named individualprovidesthefollowinginformationtothelicensingauthority:
1. HowlonghaveyoucontinuouslyresidedinWisconsinpriortothisdate?
2. Haveyoueverbeenconvictedofanyoenses(otherthantracunrelatedtoalcoholbeverages)for
violationofanyfederallaws,anyWisconsinlaws,anylawsofanyotherstatesorordinancesofanycounty
ormunicipality? ............................................................................. Yes No
Ifyes,givelaworordinanceviolated,trialcourt,trialdateandpenaltyimposed,and/ordate,descriptionand
status of charges pending.
(If more room is needed, continue on reverse side of this form.)
3. Arechargesforanyoensespresentlypendingagainstyou(otherthantracunrelatedtoalcoholbeverages)
forviolationofanyfederallaws,anyWisconsinlaws,anylawsofotherstatesorordinancesofanycountyor
municipality? ............................................................................... Yes No
Ifyes,describestatusofchargespending.
4. Doyouhold,areyoumakingapplicationfororareyouanocer,directororagentofacorporation/nonprot
organizationormember/manager/agentofalimitedliabilitycompanyholdingorapplyingforanyotheralcohol
beveragelicenseorpermit? ................................................................... Yes No
Ifyes,identify.
5. Doyouholdand/orareyouanocer,director,stockholder,agentoremployeofanypersonorcorporationor
member/manager/agentofalimitedliabilitycompanyholdingorapplyingforawholesalebeerpermit,
brewery/winerypermitorwholesaleliquor,manufacturerorrectierpermitintheStateofWisconsin? .......... Yes No
Ifyes,identify.
(Name, Location and Type of License/Permit)
(Officer / Director / Member / Manager / Agent) (Name of Corporation, Limited Liability Company or Nonprofit Organization)
(Name of Wholesale Licensee or Permittee) (Address By City and County)
6. Namedindividualmustlistinchronologicalorderlasttwoemployers.
Employer'sName Employer'sAddress EmployedFrom To
Employer'sName Employer'sAddress EmployedFrom To
READ CAREFULLY BEFORE SIGNING:Underpenaltyprovidedbylaw,theundersignedstatesthateachoftheabovequestionshas
beentruthfullyansweredtothebestoftheknowledgeofthesigner.Thesigneragreesthathe/sheisthepersonnamedintheforegoing
application;thattheapplicanthasreadandmadeacompleteanswertoeachquestion,andthattheanswersineachinstancearetrueand
correct.TheundersignedfurtherunderstandsthatanylicenseissuedcontrarytoChapter125oftheWisconsinStatutesshallbevoid,and
underpenaltyofstatelaw,theapplicantmaybeprosecutedforsubmittingfalsestatementsandadavitsinconnectionwiththisapplica-
tion.Anypersonwhoknowinglyprovidesmateriallyfalseinformationonthisapplicationmayberequiredtoforfeitnotmorethan$1,000.
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