Fillable Printable Personal/Criminal History Statement
Fillable Printable Personal/Criminal History Statement
Personal/Criminal History Statement
BLS-700-301 PERS/CRIM HISTORY (09/02/16) PAGE 1 OF 2
CONFIDENTIAL
STATE OF WASHINGTON
BUSINESS LICENSING SERVICE
PO Box 9034
Olympia, WA 98507-9034
Telephone: 1-800-451-7985
UBI NUMBER
Personal/Criminal History Statement
(For Liquor, Lottery, Gambling and Cigarette/Tobacco Wholesaler/Retailer Endorsements )
Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply.
Type of Endorsements(s) you are applying for:
You must answer "YES" if any of the above have occurred, even if charges were dismissed, deferred or changed. Explain each charge fully below and at-
tach additional sheets as needed. False or incomplete information may result in denial, suspension or revocation of a license. You must include events that
occurred while you were a juvenile.
List any business licenses that you have ever held, currently applied for, or have been denied/revoked/suspended in any state.
BUSINESS NAME: (DBA or trade name)
I AM A: SOLE PROPRIETOR CORPORATE OFFICER STOCKHOLDER FINANCIER LLC MEMBER/MGR SPOUSE
(Check all that apply)
PARTNER Title: 10% or more MANAGER OTHER:
LICENSE HISTORY
CRIMINAL HISTORY STATEMENT
LIQUOR GAMBLING CIGARETTE/TOBACCO Wholesaler/Retailer VAPOR PRODUCTS Delivery/Retailer/Sales
YES NO
TYPE LICENSE NUMBERS BUSINESS NAME STATE LAST YEAR HELD
GAMBLING
LIQUOR
LOTTERY
OTHER
(Provide a copy of this form to each agency. See page 2)
LOTTERY (complete page 1 only)
LICENSE NUMBER
Continue on to the backside of this form.
BUSINESS LOCATION ADDRESS: Street or Route City County State or Country Zip Code
HOME MAILING ADDRESS: (Street or PO Box)
State or Country:
SPOUSE’S NAME: (Last, First, Middle)
Maiden DATE OF MARRIAGE: (Month, Day and Year)
Zip Code:
HOME PHONE: WORK/CELL PHONE:
City County
NAME: (Last, First, Middle) Maiden SOCIAL SECURITY NUMBER:
If NO, give alien registration/entry visa/work permit number(s): PORT OF ENTRY:
DATE OF ENTRY: (Month, Day and Year)
ARE YOU A U.S. CITIZEN?
YES NO
Have you EVER:
3. Been convicted?
4. Been Jailed?
5. Been placed on probation?
6. Forfeited bail or paid a fine over $25
(Include traffic fines)?
1. Been arrested or cited?
2. Been charged with a crime?
RACE:
DRIVER’S LICENSE NUMBER & STATE OF ISSUE:BIRTHDATE: (Month, Day and Year) SEX:
MALE
FEMALE
HEIGHT:
WEIGHT: EYE COLOR:
HAIR COLOR:
HOW LONG LIVING AT HOME ADDRESS ABOVE:
OFFENSE DATE OFFENSE CITY COUNTY STATE DISPOSITION AND DATE
PRINT NAME:
SIGNATURE:
X
PLACE SIGNED: (City, County and State)
If applying for gambling
license, elected chief ex-
ecutive officer or employer
must also sign this form.
DATE SIGNED:
CERTIFICATION
I certify under penalty of perjury that all answers and statements on page 1 and 2 are true, correct and complete. I understand that untruthful or misleading answers are
cause for denial of a license and/or revocation of any license granted. I hereby authorize investigation of my criminal history, financial records and other sources
as necessary for licensing.
SIGNATURE:
X
DATE SIGNED:PRINT NAME:
PLACE SIGNED: (City, County and State)
Reset This Form
Print This Form
BLS-700-301 PERS/CRIM HISTORY (09/02/16) PAGE 2 OF 2
Personal/Criminal History Statement (Page 2)
APPLICANT: YOU MUST MAKE COPIES FOR EACH OF THE AGENCIES YOU HAVE CHECKED ON PAGE 1 OF THIS FORM
LIQUOR CONTROL BOARD
PO BOX 43098
OLYMPIA WA 98504-3098
GAMBLING COMMISSION
PO BOX 42400
OLYMPIA WA 98504-2400
LOTTERY COMMISSION
PO BOX 43027
OLYMPIA WA 98504-3027
List employment, self-employment, military, unemployment and school attendance for the last 10 consecutive years (including foreign residences).
If more space is needed, attach additional sheets in the same format.
EMPLOYMENT HISTORY
RESIDENCE INFORMATION
You must list all places of residence for the last 10 consecutive years (include foreign residences). List current residence first. If more
space is needed, attach additional sheets in same format.
CIGARETTE/TOBACCO
PO BOX 43098
OLYMPIA WA 98504-3098
For assistance or to request this document in an alternate format, visit http://business.wa.gov/BLS or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
LICENSE NUMBER
E-MAIL ADDRESS:
Dates From - To: TITLE: SUPERVISOR:
EMPLOYER/SCHOOL:
ADDRESS: (Street or Route) City County State or Country Zip Code
Dates From - To: TITLE: SUPERVISOR:
EMPLOYER/SCHOOL:
ADDRESS: (Street or Route) City County State or Country Zip Code
Dates From - To: TITLE: SUPERVISOR:
EMPLOYER/SCHOOL:
ADDRESS: (Street or Route) City County State or Country Zip Code
MILITARY SERVICE: (Branch and dates of service) COUNTRY OF MILITARY SERVICE: TYPE OF DISCHARGE:
FAX NUMBER:
Dates From - To:
STREET ADDRESS:
CITY: COUNTY: STATE or COUNTRY:
ZIP CODE:
Dates From - To:
STREET ADDRESS:
CITY: COUNTY:
STATE or COUNTRY:
ZIP CODE:
ADDITIONAL PERSONAL HISTORY
UBI NUMBER
OTHER NAMES USED: PREVIOUS SOCIAL SECURITY NUMBER:
PLACE OF BIRTH: City County State or Country
PLACE OF MARRIAGE: City County State or Country Zip Code
