List all owners (individuals and entities having an ownership interest), officers, directors, managers. Provide additional on an attachment. Complete Personal History Attachment (see page 7) for each person listed. Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Does the applicant or the applicant's spouse: have any interest in a management or operating company? Yes No hold an alcoholic beverage license or permit? Yes No have any interest in a company that holds an alcoholic beverage license or permit? Yes No work for any person or firm that has a direct or indirect interest in the business of an alcoholic Yes No beverage licensee or permittee? have any direct or indirect interest in the premises, equipment or fixtures used by an alcoholic Yes No beverage licensee or permittee? If to any question in number 7, provide details including trade name and license or permit number on an attachment. “Yes” If the applicant is a university, does the university a degree or certificate in hotel or motel Yes No management, restaurant management, and travel or tourism management? N/A For community colleges and/or universities: Is the applicant a state or federal agency, a political Yes No subdivision of the State, or an agency of a political subdivision of the State? Is the applicant a public community college? If provide documentation. Yes No “Yes”, Is the applicant a university? If provide documentation. Yes No “Yes”, Has the applicant or applicant's spouse ever had an interest in a issued certificate that was Yes No suspended or revoked in any U.S. state? If provide details on an attachment. “Yes”, Does your property owner hold any type of permit or license concerning the alcoholic beverage Yes No business? If provide details on an attachment. “Yes”, Has the applicant ever been charged with and/or arrested for a felony offense. If please be “Yes”, Yes No aware that additional information may be requested. This could result in processing delays. Are you submitting any optional/additional course content? Yes No The applicant understands and agrees to:
List all owners (individuals and entities having an ownership interest), officers, directors, managers. Provide additional on an attachment. Complete Personal History Attachment (see page 7) for each person listed. Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Name: Title: Percent of Ownership: Does the applicant or the applicant's spouse: have any interest in a management or operating company? Yes No hold an alcoholic beverage license or permit? Yes No have any interest in a company that holds an alcoholic beverage license or permit? Yes No work for any person or firm that has a direct or indirect interest in the business of an alcoholic beverage licensee or permittee? Yes No have any direct or indirect interest in the premises, equipment or fixtures used by an alcoholic beverage licensee or permittee? Yes No If “Yes” to any question in number 7, provide details including trade name and license or permit number on an attachment. If the applicant is a university, does the university a degree or certificate in hotel or motel management, restaurant management, and travel or tourism management? Yes No N/A For community colleges and/or universities: Is the applicant a state or federal agency, a political subdivision of the State, or an agency of a political subdivision of the State? Yes No Is the applicant a public community college? If “Yes”, provide documentation. Yes No Is the applicant a university? If “Yes”, provide documentation. Yes No Has the applicant or applicant's spouse ever had an interest in a issued certificate that was suspended or revoked in any U.S. state? If “Yes”, provide details on an attachment. Yes No Does your property owner hold any type of permit or license concerning the alcoholic beverage business? If “Yes”, provide details on an attachment. Yes No Has the applicant ever been charged with and/or arrested for a felony offense. If “Yes”, please be aware that additional information may be requested. This could result in processing delays. Yes No Are you submitting any optional/additional course content? Yes No The applicant understands and agrees to:
ST-401IBP.docx