Section 1 of 1 in this document
SUPPLEMENTAL LIST FOR ENTERTAINMENT LICENSE
Please complete for: sole proprietor/individual, each partner in a partnership, agent of the corporation or LLC, manager, officers, directors. (It is not necessary to complete this page if also applying for a Class A, Class B or Class C alcohol license at a permanent location.)
Name of Business
*
Name (First, Middle, Last)
*
Maiden and/or Previous Name(s) (if none, enter n/a)
*
Title (sole proprietor/individual, partner, agent of Corp./LLC, manager, officer, director, etc.)
*
Home Address
Street Address
City
State
Zip
Date of Birth & City and State of Birth
Date of Birth
*
City & State of Birth
*
List all states in which you previously lived (if none, enter n/a)
*
Email Address
*
Are you lawfully authorized to work in the United States?
Yes
No
disregard this