Fillable Individual History Record (Summit County Government)

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Individual History Record (Summit County Government)

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BROWSE SUMMIT COUNTY GOVERNMENT (CO) FORMS

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DR 8404-I (03/20/19)
COLORADO DEPARTMENT OF REVENUE
Liquor Enforcement Division
(303) 205-2300
Individual History Record
To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and
limited partners owning 10% or more of the partnership; all principal ofcers of a corporation, all directors of a corporation, and any
stockholder of a corporation owning 10% or more of the outstanding stock; managing members or ofcers of a limited liability company,
and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant, Tavern and
Lodging and Entertainment class of retail license
Notice: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions
must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate
so by “N/A”. Any deliberate misrepresentation or material omission may jeopardize the license application. (Please attach a
separate sheet if necessary to enable you to answer questions completely)
1. Name of Business Home Phone Number Cellular Number
2. Your Full Name (last, rst, middle) 3. List any other names you have used
4. Mailing address (if different from residence) Email Address
5. List current residence address. Include any previous addresses within the last ve years. (Attach separate sheet if necessary)
Street and Number City, State, Zip From To
Current
Previous
6. List all employment within the last ve years. Include any self-employment. (Attach separate sheet if necessary)
Name of Employer or Business Address (Street, Number, City, State, Zip) Position Held From To
7. List the name(s) of relatives working in or holding a nancial interest in the Colorado alcohol beverage industry.
Name of Relative Relationship to You Position Held Name of Licensee
8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money,
furniture, xtures, equipment or inventory to any licensee? (If yes, answer in detail.)
Yes No
9. Have you ever received a violation notice, suspension, or revocation for a liquor law violation, or have you
applied for or been denied a liquor or beer license anywhere in the United States? (If yes, explain in detail.)
Yes No
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 condential. The personal
information required in question #13 is solely for identication 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 Certicate Number i. Date of Certication 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 reect 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)
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Individual History Record (Summit County Government)

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Completed 6 August 2020

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