Individual History Record {DR 8404-I}

DR 8404-I (07/25/11) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1881 PIERCE STREET RM 108A DENVER CO 80261 To be completed by the following persons, as applicable: sole proprietors; general partners regardless of percentage ownership, and limited partners owning 10% or more of the partnership; all principal officers of a corporation, all directors of a corporation, and any stockholder of a corporation owning 10% or more of the outstanding stock; managing members or officers of a limited liability company, and members owning 10% or more of the company; and any intended registered manager of Hotel and Restaurant or Tavern class of retail license. NOTICE: This individual history record requires information that is necessary for the licensing investigation or inquiry. All questions must be answered in their entirety or the license application may be delayed or denied. If a question is not applicable, please indicate so by "N/A". Any deliberate misrepresentation or material omission may jeopardize the license application. 1. Name of Business 2. Your Full Name (last, first, middle) 4. Mailing address (if different from residence) 5. List current residence address. Include any previous addresses within the last five years (attach separate sheet if necessary). Current Previous 6. List all employment within the last five years. Include any self employment. (Attach separate sheet if necessary) 3. List any other names you have used. INDIVIDUAL HISTORY RECORD STREET AND NUMBER CITY, STATE, ZIP FROM TO NAME OF EMPLOYER OR BUSINESS ADDRESS (STREET, NUMBER, CITY, STATE, ZIP) POSITION HELD FROM TO 7. List the name(s) of relatives working in or holding a financial interest in the Colorado alcohol beverage industry. NAME OF RELATIVE RELATIONSHIP TO YOU POSITION HELD NAME OF LICENSEE 8. Have you ever applied for, held, or had an interest in a Colorado Liquor or Beer License, or loaned money, furniture, fixtures, equipment or inventory to any licensee? If yes, answer in detail. Yes No 9. Have you ever received a violation notice, suspension, or revocation for a liquor law violation, or have you applied for or been denied a liquor or beer license anywhere in the United States? If yes, explain in detail. Yes No American LegalNet, Inc. www.FormsWorkFlow.com 10. Have you ever been convicted of a crime or received a suspended sentence, deferred sentence, or forfeited bail for any offense in criminal or military court or do you have any charges pending? (If yes, explain in detail.) Yes No 11. Are you currently under probation (supervised or unsupervised), parole, or completing the requirements of a deferred sentence? (if yes, explain in detail.) Yes No 12. Have you ever had any professional license suspended, revoked, or denied? (If yes, explain in detail.) Yes No PERSONAL AND FINANCIAL INFORMATION Unless otherwise provided by law, the personal information required in question #13 will be treated as confidential. The personal information required in question #13 is solely for identification purposes. 13a. Date of Birth b. Social Security Number SSN c. Place of Birth f. When i. Date of Certification p. Sex g. Name of District Court k. Permanent Residence Card Number d. U.S. Citizen? Yes e. If Naturalized, State where h. Naturalization Certificate Number l. Height No j. If an Alien, Give Alien's Registration Card Number q. Race m. Weight n. Hair Color o. Eye Color r. Do you have a current Driver's License? If so, give number and state Yes No 14. Financial Information. a. Total purchase price $ partnership, limited liability company, other $ b. List the total amount of your investment in this business including any notes, loans, cash, services or equipment, operating capital, stock purchases or fees paid $ (if buying an existing business) or investment being made by the applying entity, corporation, c. Provide details of the Investment described in 14.b. You must account for all of the sources of this investment. Attach a separate sheet if needed. Type: Cash, Services or Equipment Source Amount d. Loan Information (attach copies of all notes or loans) Name of Lender Address Term Security Amount I declare under penalty of perjury that this application and all attachments are true, correct, and complete to the best of my knowledge. Authorized Signature Title Date Oath of Applicant American LegalNet, Inc. www.FormsWorkFlow.com