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.)

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