Alcohol Beverage License Application Supplemental Questionnaire (AT-103)

This form must be submitted to the municipal clerk, and be accompanied by one or more of the following forms: AT-104, AT-106, AT-108, AT-115, or AT-200. One form (AT-103) must be completed by EACH PERSON involved in the applicant business or parent company including:

sole proprietor
all officers, directors, and agents of a corporation or nonprofit organization
all partners of a partnership
managing members and agent of a limited liability company

Your alcohol beverage application or renewal is not complete until all required Supplemental Questionnaires are submitted.

Premises/Business Information

Registered Entity Name (or individual name if sole proprietor)

Trade Name or DBA

Entity Type (check one)

Sole Proprietor

Partnership

Limited Liability Company

Corporation

Nonprofit Corporation

Individual Information

Name (Last, First, MI)

Previous names (alias, maiden) (n/a if none)

Relationship to Registered Entity (Title)

Phone

Date of Birth

Drivers License/State ID Number

Drivers License/State ID State of Issuance

Address History

Named individual must list in chronological order their last two residence addresses within the last 5 years.

Previous Address 1

Previous City, State, Zip

Dates (MM/YYYY - MM/YYYY)

Previous Address 2

Previous City, State, Zip

Dates (MM/YYYY - MM/YYYY)

Employment History

Named individual must list in chronological order their last two employers within the last 5 years.

Employer's Name

Employer's Address

Dates Employed (MM-YYYY - MM/YYYY)

Employer's Name

Employer's Address

Dates Employed (MM/YYYY - MM/YYYY)

Criminal History

Have you ever been convicted of any offenses (other than traffic offenses unrelated to alcohol beverages) for violation of any federal, Wisconsin, or another state’s laws or of any county or municipal ordinances?

Yes

Law/Ordinance Violated

Trial Date

Penalty Imposed

Was sentence completed?

Yes

Law/Ordinance violated (enter n/a if you have no other convictions to report)

Trial Date (enter n/a if you have no other convictions to report)

Penalty Imposed (enter n/a if you have no other convictions to report)

Was sentence completed?

Yes

Law/Ordinance Violated (enter n/a if you have no other convictions to report)

Trial Date (enter n/a if you have no other convictions to report)

Penalty Imposed (enter n/a if you have no other convictions to report)

Was sentence complete?

Yes

Are charges for any offenses currently pending against you (other than traffic offenses unrelated to alcohol beverages) for violation of any federal, Wisconsin, or another state’s laws or any county or municipal ordinances?

Yes

Describe nature and status of pending charges using the space below.

Questions

Have you lived in any state other than Wisconsin as an adult?

Yes

Please list other states in the space below.

How long have you continuously lived in Wisconsin prior to the date of application?

Do you hold a direct or indirect interest in any alcohol beverage wholesaler or producer (e.g. brewer, brewpub, winery, distillery)?

Yes

Please explain using the space below.

Attestation

READ CAREFULLY BEFORE SIGNING: I understand that any license issued contrary to Wis. Stat. Chapter 125 shall be void under penalty of state law. I further understand that I may be prosecuted for submitting false statements and affidavits in connection with this application, and that any person who knowingly provides materially false information on this application may be required to forfeit not more than $1,000 if convicted.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date