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DEPARTMENT OF LIQUOR CONTROL COUNTY OF HAWAI‘I
Hilo Lagoon Centre, 101 Aupuni St., Unit 230, Hilo, Hawai‘i 96720 * Phone: (808)961-8218 * Fax: (808)961-8684
E-Mail: cohdlc@hawaiicounty.gov
PERSONAL HISTORY AND AFFIDAVIT
(Type or Print All Information)
NAME:
Last First Middle Maiden
ADDRESS: BUSINESS PHONE:
CITY: STATE: CELL PHONE:
ZIP CODE: FAX:
DATE OF BIRTH: BIRTHPLACE: EMAIL:
CITIZENSHIP: DATE ARRIVED IN HAWAI‘I:
If not a U.S. citizen indicate type of Visa, Resident Alien Card or Immigration Department No.
Please submit copy.
I. INFORMATION AS REGISTERED WITH THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS:
List registered business name and dba:
Current office/title you hold with registered business: Effective Date:
If applicable, the percentage of stocks/shares you hold:
II. LIST PAST OWNERSHIP OF LIQUOR LICENSE:
LICENSEE NAME DBA ADDRESS YEAR
III. EMPLOYMENT RECORD: (10-year history beginning with the most recent employment)
FROM TO POSITION NAME OF COMPANY CITY/STATE
If additional space is needed, use reverse side.
IV. CRIMINAL RECORD, IF ANY: Check box.
I have not been convicted of any felony charge(s).
I have been convicted of a felony charge(s). If the answer is in the affirmative, please list.
I being first duly sworn, deposes and says that the above information is true and correct.
________________________________________
Signature of Applicant before Notary
Subscribed and sworn to before me
this day of , 20 . Doc. Date: # Pages:
Name: Circuit
Notary Public (signature)
Doc. Description: Personal History Statement
ATTACH
Notary Public (print name) PHOTO
STATE OF
My commission expires:____________________
Notary Signature Date
Revised: 08/2017 Hawai‘i County is an Equal Opportunity Provider and Employer