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Form # 4 Revised 1-1-12 Page 1 of 5 DAWSON COUNTY PLANNING AND DEVELOPMENT ALCOHOL LICENSING Location & Mailing Address: 25 JUSTICE WAY, SUITE 2322 Phone: 706/344-3500 x 42335 DAWSONVILLE, GA 30534 STATEMENT OF PERSONAL HISTORY Instruction: This statement must be typed or neatly printed and executed under oath. Each question must be fully answered. If space provided is not sufficient, answer on a separate sheet and indicate in the space if a separate sheet is attached. 1. NAME: Last First Middle RESIDENCE: Street Number Street Name City State Zip Code Telephone Number 2. CHECK: (all that apply) Sole Owner/Proprietor Partner: General Limited Silent Director Principal Stockholder (20% or more) Registered Agent Officer: Manager Employee: 3. TRADE NAME OF BUSINESS FOR WHICH THIS STATEMENT IS MADE: NAME OF BUSINESS: LOCATION: Street Number Street Name P. O. Box City State Zip Code Telephone Number 4. STATE THE PERCENTAGE OF OWNERSHIP OR INTEREST, IF ANY, IN THIS BUSINESS: 5. STATE METHOD AND AMOUNT OF COMPENSATION, IF ANY, DIRECTLY OR INDIRECTLY: 6. DATE OF BIRTH: PLACE OF BIRTH: SSN: SEX: MALE FEMALE RACE: COLOR OF HAIR: COLOR OF EYES: 7. U.S. CITIZEN LEGAL PERMANENT RESIDENT QUALIFIED ALIEN OR NON-IMMIGRANT Requirements: Affidavit for Issuance of a Public Benefit and a Secure & Verifiable Document E-Verify Private Employer Affidavit of Compliance or E-Verify Private Employer Exemption Affidavit ---PAGE BREAK--- Form # 4 Revised 1-1-12 Page 2 of 5 STATEMENT OF PERSONAL HISTORY 8. SINGLE MARRIED WIDOWED DIVORCED SEPARATED IF MARRIED OR SEPARATED, COMPLETE INFORMATION LISTED BELOW: FULL NAME OF SPOUSE: SSN# MAIDEN NAME: PLACE OF BIRTH: DATE OF BIRTH: NAME AND ADDRESS OF SPOUSE'S EMPLOYER: 9. STATE ANY OTHER NAMES THAT YOU HAVE USED: MAIDEN NAME, NAMES BY FORMER MARRIAGES, FORMER NAMES CHANGED LEGALLY OR OTHERWISE, ALIASES, NICKNAMES, ETC. SPECIFY WHICH, SHOW DATES, ETC.: 10. EMPLOYMENT RECORD FOR THE PAST TEN (10) YEARS. (LIST THE MOST RECENT EXPERIENCE FIRST). From To Occupation & Salary Employer Reason for Mo/Yr Mo/Yr Duties Performed Received (Business Name) Leaving 11. LIST IN REVERSE CHRONOLOGICAL ORDER ALL OF YOUR RESIDENCES FOR THE PAST TEN (10) YEARS: From To Street City State ---PAGE BREAK--- Form # 4 Revised 1-1-12 Page 3 of 5 STATEMENT OF PERSONAL HISTORY 12. DO YOU HAVE ANY FINANCIAL INTEREST, OR ARE YOU EMPLOYED IN ANY OTHER WHOLESALE OR RETAIL BUSINESS ENGAGED IN DISTILLING, BOTTLING, RECTIFYING, OR SELLING ALCOHOLIC BEVERAGES? IF YOUR ANSWER IS "YES" TO NUMBER 14, GIVE NAMES, LOCATIONS, AND AMOUNT OF INTEREST IN EACH: 13. HAVE YOU EVER HAD ANY FINANCIAL INTEREST IN AN ALCOHOLIC BEVERAGE BUSINESS THAT WAS DENIED A LICENSE? IF SO, GIVE DETAILS: 14. HAS ANY ALCOHOLIC BEVERAGE LICENSE IN WHICH YOU HOLD, OR HAVE HELD, ANY FINANCIAL INTEREST OF, OR EMPLOYED, OR HAVE BEEN EMPLOYED, EVER BEEN CITED FOR ANY VIOLATIONS OF THE RULES AND REGULATIONS OF THE STATE REVENUE COMMISSIONER RELATING TO THE SALE AND DISTRIBUTION OF ALCOHOLIC BEVERAGES? IF SO, GIVE DETAILS: 15. IF DURING THE PAST TEN YEARS YOU HAVE BOUGHT OR SOLD ANY BUSINESS ASSOCIATED WITH ALCOHOL, GIVE DETAILS. (DATE, LICENSE NUMBER, PERSONS, AND CONSIDERATIONS INVOLVED): 16. HAVE YOU EVER BEEN DENIED BOND BY A COMMERCIAL SECURITY COMPANY? IF SO, GIVE DETAILS: 17. ARE YOU A REGISTERED VOTER? IN WHAT STATE? 18. HAVE YOU EVER BEEN ARRESTED, OR HELD BY FEDERAL, STATE OR OTHER LAW ENFORCEMENT AUTHORITIES, FOR ANY VIOLATION OF ANY FEDERAL LAW, STATE LAW, COUNTY OR MUNICIPAL LAW, REGULATION OR ORDINANCES? (Do not include traffic violations. All other charges must be included even if they were dismissed. Give reason charged or held, date, place where charged and disposition. If no arrest, write no arrest. After last arrest is listed, please write no other arrest): 1. 2. 3. 4. ---PAGE BREAK--- Form # 4 Revised 1-1-12 Page 4 of 5 STATEMENT OF PERSONAL HISTORY 19. LIST BELOW FOUR REFERENCES (PERSONAL AND BUSINESS). GIVE COMPLETE ADDRESS AND PHONE NUMBER INCLUDING AREA CODE. IF GIVING A BUSINESS REFERENCE, NAME A PERSON AT THE LOCATION TO BE CONTACTED. DO NOT INCLUDE RELATIVES OR EMPLOYERS OR FELLOW EMPLOYEES OF PARTICULAR BUSINESS. 1. 2. 3. 4. 20. HAVE YOU HAD ANY LICENSE UNDER THE REGULATORY POWERS OF DAWSON COUNTY DENIED, SUSPENDED, OR REVOKED WITHIN TWO YEARS PRIOR TO THE FILING OF THIS APPLICATION? IF SO, GIVE DETAILS: 21. ATTACH PHOTOGRAPH (Front View) TAKEN WITHIN THE PAST YEAR: NOTE: ATTACH A COPY OF YOUR DRIVER'S LICENSE TO THIS FORM. (ATTACH PHOTO HERE) ---PAGE BREAK--- Form # 4 Revised 1-1-12 Page 5 of 5 STATEMENT OF PERSONAL HISTORY 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 attachments submitted herewith. STATE OF GEORGIA, DAWSON COUNTY. I, , DO SOLEMNLY SWEAR, SUBJECT TO THE PENALTIES OF FALSE SWEARING, THAT THE STATEMENT AND ANSWERS MADE BY ME AS THE APPLICANT IN THE FOREGOING PERSONAL STATEMENT ARE TRUE AND CORRECT. FURTHER, AS PART OF THE PROCESS RESULTING FROM MY APPLICATION FOR BACKGROUND INVESTIGATION, FOR AN ALCOHOLIC BEVERAGE LICENSE. I HEREBY AUTHORIZE PERSONNEL OF THE DAWSON COUNTY SHERIFF'S DEPARTMENT OR DAWSON COUNTY MARSHAL’S OFFICE TO RECEIVE, VERIFY, AND DISSEMINATE ANY CRIMINAL HISTORY INFORMATION WHICH MAY BE IN THE FILES OF ANY LOCAL, STATE, OR FEDERAL CRIMINAL JUSTICE AGENCY FOR INVESTIGATIVE PURPOSES, DENIAL, OR APPEALS. APPLICANT'S SIGNATURE I HEREBY CERTIFY THAT SIGNED HIS/HER NAME TO THE FOREGOING APPLICATION STATING TO ME THAT HE/SHE 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 AND CORRECT. THIS, THE DAY OF . 20 NOTARY PUBLIC