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15. Give names and addresses of all children and stepchildren: (Regardless of Age) Full Name Address Age Place Of Birth Occupation A. B. C. D. E. F. 16. Give names and addresses of immediate living relatives: Full Name And Relationship Address Age Place Of Birth Occupation A. (Father) B. (Mother) C. (Brothers and Sisters) D. (Father-in-Law) E. (Mother-in-Law) 17. Are you a registered voter in the State of Georgia? ( ) Yes ( ) No In what County? How many years? 18. For the last calendar year, did you file a Georgia income tax return? ( ) Yes ( ) No How much tax did you pay? 19. For the last calendar year, did you file a Georgia intangible tax return? ( ) Yes ( ) No How much tax did you pay? 20. For the last calendar year, did you file and pay any county property tax? ( ) Yes ( ) No How much tax did you pay? Where? 21. For the last calendar year, did you file and pay any city property tax? ( ) Yes ( ) No How much tax did you pay? Where? 23. Have you ever had any financial interest in an alcoholic beverages business, which was denied a liquor license? ( ) Yes ( ) No If yes, give full details. 24. Has any alcoholic beverages business in which you hold, or have held, any financial interest, or are employed, or have been employed, ever been cited for any violation of the rules and regulations of the State Revenue Commissioners relating to the sale and distribution of alcoholic beverages? ( ) Yes ( ) No If yes, give full details. 25. Of the persons listed under Question 15 and 16, indicate which, if any, are engaged in any business handling alcoholic beverages as an owner, stockholder or employee, and the name of such business. 26. Are you a member of, or affiliated in any way with, any alcoholic beverages trade association, organization or group? ( ) Yes ( ) No If yes, give names and time of affiliation. 27. Do you pay dues, fees, or commissions, or make contributions to such organizations? ( ) Yes ( ) No If yes, state the amount paid to each for the last four calendar years. 28. Do any of the following presently have, or had in the past, any license or financial or ownership interest whatsoever in any business dealing in alcoholic beverages: spouse, parents, step-parents, parent-in-law, brothers and sisters, step-brothers and step-sisters, brothers-in-law and sisters- in-law, children, step-children and children-in-law? ( ) Yes ( ) No If yes, give details. 29. Have you during the past ten years bought and/or sold any local or state alcoholic beverage license in this State or outside this State? ( ) Yes ( ) No If yes, give details (date, license number, persons and considerations involved). 30. If during the past ten years you have bought, sold, or exchanged any real estate, automobiles, or securities with any other person engaged in the alcohol beverages business, or with any regulatory office, give full details (date, property, persons and considerations involved). 31. Have you ever visited or resided in any foreign country except while in the Armed Forces of the United States? ( ) Yes ( ) No If yes, give details. 32. Have you ever been denied a bond by a commercial surety company? ( ) Yes ( ) No If yes, give details. 33. List any close relatives (including in-laws) now residing outside the United States, except those actively serving in the Armed Forces of the United States. (Give name, relation, age, and place of residence, citizenship). 34. Education: (All schools above elementary – give name of school, address, dates attended, and degrees or certificates received). FROM TO Name of School Address Degree or Certificate Received Month Year Month Year 35. Employment Records: (Give most recent experience first. If self-employed, give details.) FROM TO Occupation and Description of Duties Performed Salaries Received Employers State Reason for Leaving Month Year Month Year ---PAGE BREAK--- 36. Lists in reverse chronological order all of your residence for the past ten years. DATES STREET CITY STATE From To 37. References. Give three personal references, not relative, former employers, fellow employees, or school teachers, who are responsible, reputable, adults, business or professional men or women, who have known you well during the past five years. (Name, residence, business address, and number of years known). 38. Military service: (Serial numbers, branch of service, period of service, type of discharge.) 39. Have you ever been arrested, or held by Federal, State, or other law-enforcement authorities, for any violation of any federal, state, county or municipal law, regulation or ordinance? (Do not include traffic violations, unless they are offenses pertaining to alcohol or drugs, such as driving under the influence.) All other charges must be included even if they were dismissed. Give reason charged or held, date, place where charged and disposition. 40. State amount of capital that is or will be invested in business. a. State amount of capital you, the applicant, personally have invested, or will invest in business. b. State amount of capital of business, which is, or will be borrowed. c. If any capital is borrowed, state name of lender(s), address of such lender(s), amount of capital borrowed for each, date of the loan(s), and true rate of interest on each. (A copy of note(s) or other evidence of indebtedness, with all amendments, must be attached to application.) Name of Lender Address Amount Date Interest Rate NOTE: Before signing this statement, check all answers and explanations to see that you have answered all questions fully and correctly. This statement is to be executed under oath and subject to the penalties of false swearing, and it includes all attached sheets submitted herewith. VERIFICATION State of Georgia, County. I, do solemnly swear, subject to the penalties of false swearing, that the statements and answers made by me as the applicant in the foregoing personnel statement are true. Applicant’s signature (Full name and in ink) I hereby certify that (the above signed person) is personally known to me, that he signed his name to the foregoing application stating to me that he knew and understood all statements and answers made therein, and, under oath actually administered by me, has sworn that said statements and answers are true. This day of in the year . Notary Public Augusta-Richmond County Board of Commissioners License & Inspection Department 1815 Marvin Griffin Road Augusta, GA 30906 ALCOHOL BEVERAGE PERSONNEL STATEMENT 1. Full name of applicant: Social Security 2. Trade name and address of business of which this personnel statement is a part: 3. Position of applicant in dealer’s business: State ownership, or profit-sharing interest, if any, in this business: Salary: Annual profit or compensation derived from this business: 4. Do you have any financial interest in any bar, lounge, tavern, restaurant, or other place of business where alcoholic beverages are sold and consumed on the business premises? ( ) Yes ( ) No If yes, give details. 5. Do you have any financial interest, or are you employed, in any wholesale or retail alcoholic beverages business other than the business submitting the license application of which this personnel statement is a part? ( ) Yes ( ) No If yes, give names, locations, and amount of interest in each. 6. Do you presently have or had in the past, any financial or ownership interest and/or presently employed, or in the past, been employed, in any business engaged in distilling, bottling, rectifying, or selling (wholesale or retail) alcoholic beverages in this State or outside this State which has not otherwise been disclosed in this statement? ( ) Yes ( ) No If yes, explain. 7. Other names used by applicant: Maiden name, names by former marriages, former names changed legally or otherwise: Aliases, nicknames, etc. Specify which and show dates used. 8. Home address: 9. Business address: 10. Place of Birth: Date of Birth: U.S. Citizen: ( ) Yes ( ) No By Birth: ( ) Yes ( ) No Naturalized: Date, Place and Court: Certificate No.: Petition No.: Derived Parents Certificate No.(s): Alien Registration No.: Native Country: Date and Port of Entry: 11. How many consecutive years and months have you been a legal resident of Georgia? Years: Months: 12. Marital Status: ( ) Married ( ) Widowed ( ) Divorced ( ) Separated 13. If married, divorced or widowed, complete the below requested information on spouse. Full name of spouse: Social Security No.: Wife’s Maiden name: Place of Birth: Date of Birth: Place of Marriage: Date of Marriage: Name of spouse’s employer: Address of employer: 14. Race: Sex: Height: Weight: Age: Color of hair: Color of eyes: