SECTION 1 – APPLICANT INFORMATION

Applicant Name (Last, First, MI)

Maiden Name

Street Address

City

State

Zip

Driver’s License Number

Social Security Number

State License Issued In:

Date of Birth

Sex

Home Phone Number

Cell Phone Number

Name and Address of establishment you will be selling alcohol

SECTION 2 – CONVICTION RECORD

Have you EVER been convicted of a felony?                                                                                                            □ YES    □ NO

If Yes; when, where and what type of violation?  (Please be specific)                                                                                              

Have you EVER been convicted of a misdemeanor or ordinance violation?                                                         □ YES     □ NO

If Yes; when, where and what type of violation?                                                                                                                                    

Do you have any PENDING criminal cases against you for violating ANY State Law or Local Ordinances?      □ YES     □ NO

OFFENSE:  __________________________________________________________________________________________

Name of Law Enforcement Agency: _____________________________________________________________________

(Attach additional pages or continue on back of this page if needed)

SECTION 3 – RENEWAL INFORMATION

I Have Completed a Responsible

Beverage Servers Training Course:

ID #                                                      

(Include a copy of your RBSTC Card)

I am Presently Enrolled in a

Responsible Beverage Servers Training Course at:                                                   which is scheduled to start on:

        /          /             

I am Exempt from this provision

because I have continuously held an Operator’s License in the following municipality:                                            

SECTION 4 – PENALTY NOTICE

I, the undersigned, make application for an Operator’s License as provided by Wisconsin State Statute 125.17. Under penalty of law, I swear that the information provided in this application is true and correct to the best of my knowledge and belief. I understand that any false information made as part of this application may be cause for denial.

Signature _________________________________________________________________   Date:________________________

FOR OFFICE USE ONLY

Date Application Received

Approve

Deny

By

Reason

Date Sent for Criminal Record

Date Criminal Record Recvd

Date Issued

Expiration Date

License Number