7325 W Forest Home Ave
Greenfield, WI 53220
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:
Your alcohol beverage application or renewal is not complete until all required Supplemental Questionnaires are submitted.
Entity Type (check one)
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?
Was sentence completed?
Was sentence complete?
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?
Have you lived in any state other than Wisconsin as an adult?
Do you hold a direct or indirect interest in any alcohol beverage wholesaler or producer (e.g. brewer, brewpub, winery, distillery)?
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.