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PERSONAL HISTORY AND AFFIDAVIT (City and County of Honolulu)

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BROWSE CITY AND COUNTY OF HONOLULU (HI) FORMS

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Reserved for Office Use (Date/Time Stamp)
LIQ-LIC-129 Page 1 of 2 Rev. 1/29/21
LIQUOR COMMISSION
CITY AND COUNTY OF HONOLULU
711 KAPIOLANI BOULEVARD, SUITE 600, HONOLULU, HAWAII 96813-5249
PHONE (808) 768-7300 • EMAIL HLC@honolulu.gov
INTERNET ADDRESS: www.honolulu.gov/liq
PERSONAL HISTORY AND AFFIDAVIT
Rule 3-83-53.1
SOCIAL
NAME _________________________________________________________________ SECURITY NO.__ __ __ ˗ __ __ ˗ __ __ __ __
(Last, First Middle Maiden)
RESIDENTIAL ADDRESS ____________________________________________________________ APT. NO. _________________
CITY ____________________________________________________ STATE ______________ ZIP CODE _____________________
BUS. PH (_____) _________________ MOBILE PH (_____) ________________ EMAIL ___________________________________
PLACE DATE MARITAL
OF BIRTH _________________________________ OF BIRTH ___________________ AGE _______ STATUS ________________
(City, State) (MM / DD / YYYY)
NO. OF YEARS COMPLETED IN HIGH SCHOOL _________________________ YEAR COMPLETED _____________________
NAME OF HIGH SCHOOL ______________________________________________________________________________________
(include City and State)
NO. OF YEARS COMPLETED IN COLLEGE _____________________________ YEAR COMPLETED _____________________
NAME OF COLLEGE ___________________________________________________________________________________________
(include City and State)
OTHER EDUCATION / YEAR(S) ATTENDED ______________________________________________________________________
DATE ARRIVED IN
CITIZENSHIP* _________________________________________________________ HAWAII (if applicable) ___________________
*If not a U.S. citizen, indicate type of Visa, or Resident Alien Card No., or Immigration Department No.
EMPLOYMENT RECORD (from the time school was completed to present; also indicate any periods of unemployment):
FROM TO
MONTH/YEAR MONTH/YEAR POSITION EMPLOYER LOCATION
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
(If additional space is needed, please attach a separate sheet)
NOTARY INITIAL: _______________
LIQ-LIC-129 Page 2 of 2 Rev. 1/29/21
List your experience in the liquor industry: ________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Will you devote time to manage the subject business?
YES NO
If answer is "YES", will it be
FULL TIME, or PART-TIME?
I, _________________________________________ , of _____________________________________________
(Print Applicant’s Full Name) (Residential Address, City, State, Zip Code)
being first duly sworn, deposes, and says, that the above information is true and correct and that I
(
have or have not) been convicted of any felony charge.
_________________________________________________
Signature
┌ ┐
PASSPORT-TYPE PHOTOGRAPH
REQUIRED - - NO SNAPSHOTS OR
PHOTOCOPIES WILL BE ACCEPTED.
AFFIX 2" X 2" PHOTOGRAPH HERE.
└ ┘
FOR NOTARY USE ONLY
STATE OF HAWAII
City and County of Honolulu
}
SS.
On this ____________ day of _______________, in the year of ____________, personally appeared
____________________________________________________________________________________
who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to within the foregoing
instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the aforementioned instrument the person, or the entity upon behalf of which the person(s) acted,
executed the aforementioned instrument in free act and deed.
__________________________________________________________
Signature of applicant(s) before Notary
Subscribed and sworn to before me this:
________ day of _______________________________________ , 20 ______
_____________________________________________________________________________________
Signature of Notary
Print Name: __________________________________________________________________________
Notary Public, State of Hawaii
My commission expires ___________________________________________________
(Place Notary Stamp or Seal here)
NOTARY CERTIFICATION
Date of Doc: _____________________________ # of Pages: ________________
Notary Name: ______________________________________________ _____ Circuit
Doc. Description: _________________________________________________________
________________________________________________________________________
_____________________________________________ _______________________
Notary Signature Date
(Place Notary Stamp or Seal here)
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PERSONAL HISTORY AND AFFIDAVIT (City and County of Honolulu)

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Completed 14 June 2021

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