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Background Investigation License/Permit This addendum becomes a part of the License/Permit Application submitted and is attached thereto as referenced by the number above. The information shown below is personal information about the applicant for license to be used for background investigations in the review of licensing request and will be handled as confidential. If requesting more than one license, duplicate background reports will not be required. Fees associated with the background report are based on the current fee charged by the company providing the report and can be quoted by personnel prior to application submittal. NOTE: Cabaret License and/or Liquor license applicants must complete this application in its entirety – all other applicants required to submit this addendum for background history need only complete the highlighted areas. Applicant Personal Information: $15 Fee Full name of person being investigated: Date of birth: Hair color: Sex: male female Height: Place of birth: Eye color: Race: Weight: Lbs. Alias: Web site: Current Occupation: Driver’s License State of driver’s license issuance: Social Security Total years at current address: Are you a naturalized citizen of the United States of America? yes no Naturalization Please list all of the addresses in which you have resided for the past five years (address, city, state, zip code): more on back Applicant’s Bank: Name Address Phone Type of Account Spouse’s Bank: Name Address Phone Type of Account Please list all arrests and convictions, including traffic violations (continue on back if additional room is needed) more on back Date: Date: Location: Location: Final disposition: Final disposition: Employment History Please list current employer, then list all employment for the last 10-years. Please continue of back if additional room is needed. more on back I am currently unemployed Business Name Business Address Street, City, State, Zip Phone Position Held Dates of Employment ---PAGE BREAK--- Page 2 of 3 License Application – Background Investigation Addendum Form121212ps Background Investigation License/Permit References Name Address Phone Years Acquainted Please list three professional references Please list three personal references NOTICE AND AFFIRMATION The City of Brighton, by law, has the authority to regulate licenses. Pursuant to this authority, the City may conduct a background investigation of owners and managers. The Background Investigation report provides basic information about the applicant that is necessary for the investigation and review of licensing. All applicable questions must be answered completely. A deliberate falsehood will jeopardize the application, as such falsehood, within itself, constitutes evidence regarding the reputation and character of the applicant. I have read and understand this notice as written. I hereby certify the facts contained within the foregoing Background Investigation report are true and correct, and I understand that any falsification or misrepresentation on my part will result in a rejection of this application. I affirm this statement by my signature affixed hereto: Applicant’s Signature Date (Notarization only required for liquor license applicants) At Witness: Sworn before me this day of Notary Public My commission (SEAL) ---PAGE BREAK--- Page 3 of 3 License Application – Background Investigation Addendum Form121212ps Background Investigation License/Permit Background Investigation Report – City of Brighton Police Department Office Use Only Fingerprints: Search File complete yes no Assigned Recommendation for License Approval Denial Signature – Chief of Police (designee) Attachment: yes no Additional notes: