Form L-PHS (10/2019)
List employment for the past five (5) years beginning with your current employer. If self-employed or retired, include the name of your
company or company from which you retired, type of business owned or the position held prior to retirement. Include periods of
unemployment. All periods of time must be accounted for during the past five years. (If additional space is needed, attach a separate
Address (Street, City, State, ZIP)
INDIVIDUAL FINANCIAL INFORMATION
List the total amount of your personal investment in this location. Provide investment details including notes, loans, gifts,
cash, services or equipment, and operating capital. Account for the original source of all investments (how acquired).
Enter total dollar amount on the line of the amount invested column.
(If additional space is needed, attach a separate sheet.)
NOTE: If investment is in the form of a loan or gift, attach name of lender or financial institution, address, terms and
security and loan/gift documents. If from an individual, attach personal information for all individuals including:
name, social security and driver license numbers, date of birth, race, sex, etc.
Original Source of Investment (loans, previous employment, etc).
TOTAL AMOUNT OF PERSONAL INVESTMENT
SIGN AND NOTARIZE APPLICATION
WARNING: Section 101.69 of the Texas Alcoholic Beverage Code states: “…a person who makes a false statement or false
representation in an application for a permit or license or in a statement, report, or other instrument to be filed with the Commission and
required to be sworn commits an offense punishable by imprisonment in the Texas Department of Criminal Justice for not less than 2 nor
more than 10 years.”
I, under penalty of law, hereby swear that I have read all the information provided in this document and any attachments and the
information is true and correct. I also understand any false statement or representation in this application can result in my application
being denied and/or criminal charges filed against me. I also authorize the Texas Alcoholic Beverage Commission to use all legal means
to verify the information provided.
BEFORE ME, the undersigned authority, on this day of , 20 the person whose
name is signed to the foregoing document personally appeared and duly sworn by me, each states under oath that he or she
has read the said document and that all facts therein set forth are true and correct.
(S E A L) Notary Public