Auxiliary Questionnaire (City Of Milwaukee Use Only) {AT-103a}

AUXILIARY 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) PostOffice City State ZipCode 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? . . . . . . . . . 2. (a) Haveyoueverbeenconvictedofanyoffenses(otherthantrafficunrelatedtoalcoholbeverages) for violation of any federal laws, any Wisconsin laws, or laws of any other states? . . . . . . . . . . . . . . . . . . . . . . . (b) Have you ever been convicted of any violations of any county or municipal ordinances? . . . . . . . . . . . . . . . . . . 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. Arechargesforanyoffensespresentlypendingagainstyou(otherthantrafficunrelatedtoalcoholbeverages) for violation of any federal laws, any Wisconsin laws, any laws of other states or ordinances of any county or municipality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, describe status of charges pending. 4. Doyouhold,areyoumakingapplicationfororareyouanofficer,directororagentofacorporation/nonprofit organization or member/manager/agent of a limited liability company holding or applying for any other alcohol beverage license or permit?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, identify. (Name, Location and Type of License/Permit) Yes Yes Yes No No No Yes No Yes No 5. Doyouholdand/orareyouanofficer,director,stockholder,agentoremployeofanypersonorcorporationor member/manager/agent of a limited liability company holding or applying for a wholesale beer permit, brewery/winerypermitorwholesaleliquor,manufacturerorrectifierpermit in the State of Wisconsin? . . . . . . . . . . . (If yes, identify.) (Name of Wholesale Licensee or Permittee) (Address by City and County) Yes No READ CAREFULLY BEFORE SIGNING: I, The undersigned, shall not willfully refuse to provide those services offered under this license, orrefusetoemployordischargeanypersonotherwisequalifiedbecauseofrace,color,creed,sex,nationaloriginorancestry;Ishallnot seek information as a condition of employment, or penalize any employe or discriminate in the selection of personnel for training or promotion 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. Theundersigned,beingfirstdulyswornonoath,deposesandsaysthathe/sheisthepersonnamedintheforegoingapplication;thatthe 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 ofstatelaw,theapplicantmaybeprosecutedforsubmittingfalsestatementsandaffidavitsinconnectionwiththisapplication. Subscribed and sworn to before me this day of (Clerk/Notary Public) , 20 (Signature of Named Individual) My commission expires AT-103a (R. 8-11) Wisconsin Department of Revenue American LegalNet, Inc. www.FormsWorkFlow.com