10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited
bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.)
Yes No
11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a
deferred sentence? (If yes, explain in detail.)
Yes No
12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.)
Yes No
Personal and Financial Information
Unless otherwise provided by law, the personal information required in question #13 will be treated as condential. The personal
information required in question #13 is solely for identication purposes.
13a. Date of Birth b. Social Security Number c. Place of Birth
d. U.S. Citizen
Yes No
e. If Naturalized, state where f. When g. Name of District Court
h. Naturalization Certicate Number i. Date of Certication j. If an Alien, Give Alien’s Registration Card Number k. Permanent Residence Card Number
l. Height m. Weight n. Hair Color o. Eye Color p. Gender q. Do you have a current Driver’s License/ID? If so, give number and state.
Yes No # __________________ State _________________
14. Financial Information.
a. Total purchase price or investment being made by the applying entity, corporation, partnership, limited liability company, other.
$ _________________________________
b. List the total amount of the personal investment , made by the person listed on question #2, in this business including any
notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid. $ __________________________
* If corporate investment only please skip to and complete section (d)
** Section b should reect the total of sections c and e
c. Provide details of the personal investment described in 14b. You must account for all of the sources of this investment.
(Attach a separate sheet if needed)
Type: Cash, Services or Equipment Account Type Bank Name Amount
d. Provide details of the corporate investment described in 14 (a). You must account for all of the sources of this investment. (Attach a
separate sheet if needed)
Type: Cash, Services or Equipment Loans Account Type Bank Name Amount
e. Loan Information (Attach copies of all notes or loans)
Name of Lender Address Term Security Amount
Oath of Applicant
I declare under penalty of perjury that this application and all attachments are true, correct, and complete to the best of my knowledge.
Authorized Signature Print Signature Title Date
DR 8404-I (03/20/19)