OREGON LIQUOR CONTROL COMMISSION
Marijuana Business Individual History Form
[FORM MJ 17-1010] mj_app_ih (20201015) Page 1 of 1
Section 1 – Individual History Statement
Which of the following best
describes you? You may
choose to opt-out of responding.
If you have a social security number, this
field is required. See disclosure below.
I do not have a Social
*SOCIAL SECURITY NUMBER DISCLOSURE: As part of your application for an initial or renewal license, Federal and
to provide your Social Security Number (SSN) to the Oregon Liquor Control Commission (OLCC) for
support enforcement purposes (42
USC § 666(a)(13) & ORS 25.785). If you are an applicant or licensee and fail to provide
SSN, the OLCC may refuse to process your
application. Your SSN will be used only for child support enforcement
unless you confirm your agreement that OLCC can use it for
administrative purposes as well.
Based on our authority under ORS 475B.040 and OAR 845-025-1080(2), we are requesting your voluntary consent to use
N for the
following administrative purposes only: to positively confirm your identity during the criminal records check. OLCC will not deny you any rights,
privileges otherwise provided by law if you do not consent to use of your SSN for these administrative purposes (5 USC§
check the appropriate box next to the social security field indicating whether you consent or do not consent.
Do you consent to use of SSN for purposes of confirming identity during a criminal records check?
Have you ever been convicted of a felony?
(If yes, attach an explanation. A conviction will not necessarily prevent you from obtaining a license.)
Do you have any arrests or citations for misdemeanor or felony changes that are not resolved?
(If you are arrested, cited, or convicted after completing this document but before receiving an OLCC license, you must
immediately notify your assigned investigator and submit a revised Individual History form. Failure to do so may result in
license denial or cancellation.)
Please list the business name and license number or premises number of every OLCC liquor license or marijuana license
(including research certificate or retail liquor agent) that you have applied for or received. This includes having a financial
interest or ownership interest in a legal entity that applied for or held the license.
Name of any business under which you have applied for or held any OLCC marijuana or liquor license:
Section 2 – Acknowledgement
You must sign your own form. You cannot have your attorney or a person with power of attorney sign your form.
I affirm that my answers are true and correct. I understand that if my answers are not true and correct that the OLCC may deny my
application. I understand that I must notify the Commission within 24 hours if I am arrested, cited or convicted for any misdemeanor or
felony after submitting this form.
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