Form At-103 - Auxiliary Questionnaire Alcohol Beverage License Application
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1AUXILIARY QUESTIONNAIRE
ALCOHOL BEVERAGE LICENSE APPLICATION
Submit to municipal clerk.
Individual's Full Name (please print)
(last name)
(first name)
(middle name)
Home Address (street/route)
Post Office
City
State
Zip Code
Home Phone Number
Age
Date of Birth
Place of Birth
The above named individual provides the following information as a person who is
:
(check one)
Applying for an alcohol beverage license as an individual.
A member of a partnership which is making application for an alcohol beverage license.
of
(Officer/Director/Member/Manager/Agent)
(Name of Corporation, Limited Liability Company or Nonprofit Organization)
which is making application for an alcohol beverage license.
The above named individual provides the following information to the licensing authority:
1. How long have you continuously resided in Wisconsin prior to this date?
2. Have you ever been convicted of any offenses (other than traffic unrelated to alcohol beverages) for
violation of any federal laws, any Wisconsin laws, any laws of any other states or ordinances of any county
or municipality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, give law or ordinance violated, trial court, trial date and penalty imposed, and/or date, description and
status of charges pending.
(If more room is needed, continue on reverse side of this form.)
3. Are charges for any offenses presently pending against you (other than traffic unrelated to alcohol beverages)
for violation of any federal laws, any Wisconsin laws, any laws of other states or ordinances of any county or
municipality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, describe status of charges pending.
4. Do you hold, are you making application for or are you an officer, director or agent of a corporation/nonprofit
organization or member/manager/agent of a limited liability company holding or applying for any other alcohol
beverage license or permit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, identify.
(Name, Location and Type of License/Permit)
5. Do you hold and/or are you an officer, director, stockholder, agent or employe of any person or corporation or
member/manager/agent of a limited liability company holding or applying for a wholesale beer permit,
brewery/winery permit or wholesale liquor, manufacturer or rectifier permit in the State of Wisconsin? . . . . . . . . . .
Yes
No
If yes, identify.
(Name of Wholesale Licensee or Permittee)
(Address By City and County)
6. Named individual must list in chronological order last two employers.
Employer's Name
Employer's Address
Employed From
To
Employer's Name
Employer's Address
Employed From
To
The undersigned, being first duly sworn on oath, deposes and says that he/she is the person named in the foregoing application; that
the applicant has read and made a complete answer to each question, and that the answers in each instance are true and correct. The
undersigned further understands that any license issued contrary to Chapter 125 of the Wisconsin Statutes shall be void, and under
penalty of state law, the applicant may be prosecuted for submitting false statements and affidavits in connection with this application.
Subscribed and sworn to before me
this
day of
, 20
(Signature of Named Individual)
(Clerk/Notary Public)
My commission expires
Printed on
Recycled Paper
AT-103 (R. 8-11)
Wisconsin Department of Revenue
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