300 Washington Street
Brookline, MA 02445
Phone : 617-383-6000 * Fax : 617-383-6001
Personal Information
(
Each Owner and Manager must fill out
)
1. Name:
2. Address:
3. Ownership % in Company:
4. Date of Birth:
5. Place of Birth:
6. Social Security Number: (For Criminal CORI request)
7. Mother"s First Name and Maiden Name:
8. Father"s Full Name:
9. Driver"s License Number & State:
10. Height / Weight / Eye Color (For Criminal CORI request)
Licensing Client Questionnaire - Multiple Owners © 2022 RLAW P.C. Page 1
11. Cell Phone Number:
12. E-mail Address:
13. Criminal History Details (if applicable)
14. Place of Employment:
15. Do you currently have an interest in any other liquor licenses?
YES
NO
If yes, name all licenses:
Licensing Client Questionnaire - Multiple Owners © 2022 RLAW P.C. Page 2
16. Have you previously held a liquor license?
YES
NO
If yes, please list the type of license and the date of ownership surrendered, and how license was terminated:
17. If your license has ever been suspended, list when/license/ reasons:
Licensing Client Questionnaire - Multiple Owners © 2022 RLAW P.C. Page 3
Submit
Should be Empty: