TAVERN OPERATOR'S LICENSE APPLICATION

€ New € Renewal License Period: 7/1/ ____ to 6/30/ ____

Applicant Name________________________________________________________________________________________

Last First Middle Maiden

Residence Address_____________________________________________________________________________________

Street Number Street City Zip

Mailing Address_______________________________________________________________________________________

Street Number Street City Zip

Date of Birth _______________________ Place of Birth __________________________________________

List your places of Residence for the Past Ten (10) Years FROM / TO

________________________________________________________________________________________________________________

Have you ever been convicted of:

Violating any Federal or State Criminal Statute? Yes____ No____

Violating any traffic law that resulted in death or serious injury? Yes____ No____

Violating any Federal, State or Local alcohol or drug laws (Including operating a motor vehicle under the influence)? Yes____ No____

Violating any municipal ordinance law in the past five years (other than traffic laws or parking)? Yes____ No____

Do you have pending charges for any of the above violations? Yes____ No____

If you have answered "Yes" to any of the above questions, you must provide the following information as to each incident.

Date of Offense ï Offense ï Disposition ï Issuing/Arresting Agency

________________________________________________________________________________________________________________

Employer for whom the license is requested ________________________________________________________________________________________________________________

________________________________________________________________________________________________

(Employer's Signature)

The undersigned, upon penalty of perjury, declares the foregoing application to be complete and accurate. Furthermore, I hereby empower the City of Lake Mills and any of it's agents to obtain information pertaining to me and do hereby release any agency, business or individual from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information or any attempt to comply with it.

Subscribed and sworn to before me

This ____________ day of _________________, 20____. _______________________________________________

APPLICANTS SIGNATURE

______________________________________________

Clerk-Notary Public

My commission expires: __________________________

TO BE FILLED OUT BY THE CITY OF LAKE MILLS POLICE DEPARTMENT

€ Subject has no Criminal Arrest Record with either the Wisconsin State Crime Bureau or with the Lake Mills Police Department.

€ Files indicate that subject has the Criminal Arrest Record (see attached).

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Signature Police Chief Date