Form At-103a - Auxiliary Questionnaire Alcohol Beverage License Application

AUXILIARY QUESTIONNAIRE

ALCOHOL BEVERAGE LICENSE APPLICATION

Submit to municipal clerk.

Individual's Full Name (please print)

(last name)

(first name)

(middle name)

Post Office

City

State

Zip Code

Home Address (street/route)

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. (a) How long have you continuously resided in Wisconsin prior to this date?

(b) Have you resided in the City of Milwaukee continuously for one year immediately prior to this date? . . . . . . . . .

Yes

No

2. (a) Have you ever been convicted of any offenses (other than traffic unrelated to alcohol beverages)

for violation of any federal laws, any Wisconsin laws, or laws of any other states? . . . . . . . . . . . . . . . . . . . . . . .

Yes

No

(b) Have you ever been convicted of any violations of any county or municipal ordinances? . . . . . . . . . . . . . . . . . .

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)

READ CAREFULLY BEFORE SIGNING: I, The undersigned, shall not willfully refuse to provide those services offered under this license,

or refuse to employ or discharge any person otherwise qualified because of race, color, creed, sex, national origin or ancestry; I shall not

seek information as a condition of employment, or penalize any employe or discriminate in the selection of personnel for training or pro-

motion solely on the basis of such information. I also shall not discriminate against any member of the military service dressed in uniform

by willfully refusing services offered under this license.

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 un-

dersigned 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

(Clerk/Notary Public)

(Signature of Named Individual)

My commission expires

AT-103a (R. 8-11)

Wisconsin Department of Revenue