1/11/2018 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999
I (Print Full Name) ______________________________________________ hereby declare that I am the Agent/ Controlling Person /
Premises Manager filing this application. I have read this document and verify the contents and all statements are true,
correct and complete, to the best of my knowledge.
Signature: ___________________________________________ State of _________________ County of _______________________
The foregoing instrument was acknowledged before me this
My Commission Expires on: ___________________________ ___________ Day of _____________________, ___________
Date Day Month Year
nature of Notary
If you answered “YES” to any Question 14 through 18 YOU MUST attach a signed statement.
Give complete details including dates, agencies involved and dispositions.
CHANGES TO QUESTIONS 14-18 MAY NOT BE ACCEPTED
11. Provide your residence address information for the last five (5) years:
RESIDENTIAL Street Address
(ATTACH ADDITIONAL SHEET IF NECESSARY)
The Licensee has authorized the person named on this questionnaire to act as manager for the above License.
PRINT NAME: _______________________________________________________________ SIGNATURE: _______________________________________________________________
12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises?
If you answered YES, then answer #13 below. If NO, skip to #14.
13. Have you attended a DLLC approved Basic & Mana
ement Liquor Law Trainin
Course within the past 3
14. Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminal
law or ordinance, regardless of the disposition, even if dismissed or expunged, within the past five (5) years?
15. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or
summonses pending against you? (Do not include civil traffic tickets.) A.R.S.§4-202,4-210
16. Has anyone EVER obtained a
ainst you the sub
ect of which involved fraud o
17. Have you had a liquor application or license re
ected, denied, revoked or suspended in or outside of Arizona
within the last five years?
18. Has an entity in which you are or have been a controlling person had an application or license rejected,
denied, revoked or suspended in or outside of Arizona within the last five years? A.R.S.§4-202(D)