Department of Alcoholic Beverage Control
State of California
Gavin Newsom, Governor
INDIVIDUAL PERSONAL AFFIDAVIT
Instructions: This form must be completed by: sole owners and their spouses; each general partner
and their spouses; officers of a corporation and a majority of the board of directors; persons holding
10% or m ore of the capital or s tock of a corporation and their spouses; persons holding 10% or more
of the capital or stock of a limited liability company or li mited partnership and their spouses.
If I tem #23b is checked, you must complete Form ABC-208-B, Financial Affidavit.
FINGERPRINTING (ABC USE ONLY)
Active Livescan
Date:
1. FIRST NAME MIDDLE NAME LAST NAME 2. PREVIOUS NAME(S) (Include maiden name, aka, alias)
3. PREMISES ADDRESS 4. PREMISES TELEPHONE NUMBER
5. HOME ADDRESS 6. HOME TELEPHONE NUMBER
7. SOCIAL SECURITY NUMBER 8. DRIVER'S LICENSE OR ID NUMBER 9. STATE WHERE DL OR ID ISSUED 10. WORK OR CELL TELEPHONE NUMBER
11. PERSONAL DATA
Male Female
HEIGHT WEIGHT EYE COLOR HAIR COLOR
12. BIRTHDATE 13. BIRTHPLACE (City, State, Country) 14. MARITAL STATUS
Single Divorced Widow(er)
Married Separated Registered Partner
SPOUSE'S/REGISTERED PARTNER'S NAME (Last, first, middle) (Include alias) 16. MARRIAGE DATE 17. MARRIAGE PLACE (City, State)
18. I AM OR WILL BE
Sole Owner
Spouse/Registered Partner
Partner
General Partner
Limited Partner
Manager
Food Lessee
Director
Stockholder
Officer
LLC Member/Managing Member
Title:
19. Do you now have any direct, or ind irect, interest in any other a lcoholic beverage business, or h ave you ever b een an alcoholic
beverage licensee or a n officer o r d irector o f a corporate licensee in or o utside of California?
Yes No
IF YES, EXPLAIN (List License number and/or premises address)
20. Have you as an individual, a partner, or w hile an officer, director, or s tockholder o f a corporation ever h ad an alcoholic
b
everage license denied, suspended, revoked, or a n offer in compromise accepted or r ejected?
Yes
21. EMPLOYMENT HISTORY (Past five years - include unemployed, student, homemaker, etc. Use additional sheets if needed.)
FROM (MONTH/YEAR) TO (MONTH/YEAR) JOB TITLE COMPANY NAME AND CITY
22. Have you ever, anywhere or a t any time, (1) f orfeited bail, (2) b een convicted, (3) f ined, or ( 4) p laced on probation for a ny
v
iolation of the law? (5) A re you now actively being prosecuted for a criminal offense
?
(If any of these events has occurred, this question must be answered "Yes" regardless of subsequent court action resulting in
expungement, unless an order sealing records under Section 1203.45 of the Penal Code, relating to persons under age 18 years,
has been issued. If no order has been issued, the answer must be "Yes.") Yes No
ARREST DATE PLACE OF ARREST OFFENSE RESULT/DISPOSITION
23. FINANCIAL CONTRIBUTION TO THE BUSINESS (If Box B is checked, complete Form ABC-208-B)
A. I am not making a contribution in any form
B. I am making a financial contribution
C. I am contributing labor/expertise only
D. Same as the affidavit of
I have read all of the above and declare under penalty of perjury that each and every statement
is true, correct and complete.
DATE SIGNED PLACE SIGNED ATTEST (ABC EMPLOYEE OR NOTARY PUBLIC)
ABC-208-A (rev. 01-19)
