Fillable QUESTIONNAIRE A.R.S.4-202, 4-210 Arizona Department of Liquor Licenses (Arizona Department of Liquor Licenses and Control)

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QUESTIONNAIRE A.R.S.4-202, 4-210 Arizona Department of Liquor Licenses (Arizona Department of Liquor Licenses and Control)

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BROWSE ARIZONA DEPARTMENT OF LIQUOR LICENSES AND CONTROL (AZ) FORMS

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1/11/2018 Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-2999
The fees allowed by R19-1-102 will be charged for all dishonored checks.
ATTENTI0N APPLICANT: This is a legally binding document. Please type or print in black ink. An investigation of your
background will be conducted. Incomplete applications will not be accepted. False or misleading answers may result in the
denial or revocation of a license or permit and could result in criminal prosecution.
Attention local governments: Social security and birth date information is confidential. This information may be given to law
enforcement agencies for background checks only.
QUESTIONNAIRE IS TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER BEING DISCLOSED TO THE DEPARTMENT. EACH
PERSON COMPLETING THIS FORM MUST SUBMIT A BLUE OR BLACK LINED FINGERPRINT CARD ALONG WITH A $22 FEE. FINGERPRINTS MUST BE DONE
BY A LAW ENFORCEMENT AGENCY OR BONA FIDE FINGERPRINT SERVICE. FOR AN ADDITIONAL $13 FEE, FINGERPRINTS MAY BE DONE AT THE
DEPARTMENT OF LIQUOR WHEN ACCOMPANIED BY A COMPLETED APPLICATION.
Liquor License#:
1. Check the
Appropriate
Box
2. Name: _____________________________________________________________________________________ Birth Date:_____/_____/______
Last First Middle (NOT a public record)
3. Social Security #: ____________________________ Driver License#: ______________________________ State: ______________________
4. Place of birth: ______________________________________________ Height: ________ Weight: ________ Eyes: _______ Hair: ________
City State COUNTRY (not county)
5. Name of current/most recent spouse: ________________________________________________________ Birth Date: _____/_____/_____
Last First Middle (NOT a public record)
6. Are you a bona fide resident of Arizona?Yes No If yes, what is your date of residency: _____________________________
7. Daytime telephone number: ____________________________ E-mail address: _________________________________________________
8. Business Name:
______________________________________________________________________ Business Phone: _____/______/______
9. Business Location Address: ______________________________________________________________________________________________
Street (do not use PO Box ) City State County Zip
10. List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.
FROM
Month/Yea
r
TO
Month/Yea
r
DESCRIBE POSITION OR BUSINESS
EMPLOYERS NAME OR NAME OF BUSINESS
(
Street Address, City, State & Zip
)
CURRENT
(A
TTACH ADDITIONAL SHEET IF NECESSARY)
Controlling Person Agent Premises Manager
(complete all questions except #12)
Arizona Department of Liquor Licenses and Control
800 W Washington 5
th
Floor
Phoenix, AZ 85007-2934
www.azliquor.gov
(602) 542-5141
QUESTIONNAIRE
A.R.S.§4-202, 4-210
Type or Print with Black Ink
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
___________________________________________________
Si
g
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:
A.R.S. §4-202(D)
FROM
Month/Year
TO
Month/Year
RESIDENTIAL Street Address
CURRENT
(ATTACH ADDITIONAL SHEET IF NECESSARY)
NOTARY
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.
Yes No
13. Have you attended a DLLC approved Basic & Mana
g
ement Liquor Law Trainin
g
Course within the past 3
years?
Yes No
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?
Yes No
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
Yes No
16. Has anyone EVER obtained a
j
ud
g
ement a
g
ainst you the sub
ect of which involved fraud o
r
misrepresentation?
Yes No
17. Have you had a liquor application or license re
j
ected, denied, revoked or suspended in or outside of Arizona
within the last five years?
A.R.S.§4-202(D)
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)
Yes No
Yes No
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QUESTIONNAIRE A.R.S.4-202, 4-210 Arizona Department of Liquor Licenses (Arizona Department of Liquor Licenses and Control)

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Completed 12 August 2020

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