Form TTB F 5000.9 TTB F 5000.9 Personnel Questionnaire - Alcohol and Tobacco Products

OMB No. 1513-0002 (01/31/09)
DATE

DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

PERSONNEL QUESTIONNAIRE - ALCOHOL AND TOBACCO PRODUCTS
SUPPLEMENTAL TO APPLICATION FOR PERMIT FILED BY:
TRADE OR CORPORATE NAME TO BE USED (If any)
BUSINESS ADDRESS OF FIRM (No., street, city, State,
and ZIP Code)
FULL NAME OF APPLICANT (Do not use initials)

NAME USUALLY USED

LEGAL RESIDENCE (No., street, city, State, and ZIP
Code)

TELEPHONE NUMBER

MALE

HEIGHT

FEMALE

FT.

WEIGHT
IN.

POSITION OR TITLE

COLOR OF
HAIR

COLOR OF
EYES

TELEPHONE NUMBER

IF A MARRIED WOMAN, GIVE FULL
MAIDEN NAME & DATE OF MARRIAGE
BUSINESS ADDRESS (No., street, city,
State, and ZIP Code)
PLACE OF BIRTH

TELEPHONE NUMBER

DATE OF BIRTH SOCIAL SECURITY NO.

LBS.
DESCRIPTION OF DUTIES OR RELATION TO THE PROPOSED OPERATION

FATHER’S NAME

MOTHER’S MAIDEN NAME

If the answer to any of the following questions, 1 through 6, is “YES,” give full details under remarks or on a separate sheet, taking care to
number the reply to correspond with the question. Convictions, arrests, or charges for minor traffic violations need not be reported.
1. HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAME (Include nicknames, aliases)?
2 . HAVE YOU EVER BEEN ARRESTED FOR ANY VIOLATION OF ANY FEDERAL OR STATE LAW RELATING TO LIQUOR OR TOBACCO PRODUCTS?
3. HAVE YOU EVER BEEN ARRESTED FOR VIOLATION OF ANY OTHER FEDERAL OR STATE LAW?
4. HAVE YOU EVER BEEN CONVICTED OF ANY FELONY OR MISDEMEANOR UNDER FEDERAL OR STATE LAW?
5. HAVE YOU EVER BEEN COMPROMISED, BY PAYMENT OF PENALTIES OR OTHERWISE, FOR ANY VIOLATION OF ANY FEDERAL LAW
RELATING TO INTERNAL REVENUE OR CUSTOMS TAXATION OF DISTILLED SPIRITS, WINES, BEER, OR TOBACCO PRODUCTS?
6. HAS DISAPPROVAL EVER BEEN GIVEN TO ANY APPLICATION OR NOTICE OF INTENTION TO MANUFACTURE, USE, STORE,
RECTIFY, BOTTLE, DISTRIBUTE, SELL, IMPORT, OR TRANSPORT ALCOHOL, DENATURED SPIRITS, DISTILLED SPIRITS, BEER,
WINES, OR TOBACCO PRODUCTS FILED BY YOU OR ANY FIRM OR CORPORATION OF WHICH YOU WERE PROPRIETOR OR
A PARTNER, OFFICER, DIRECTOR, PRINCIPAL STOCKHOLDER, OR RESPONSIBLE EMPLOYEE?
IF ANSWER IS “YES,” STATE NAME UNDER WHICH APPLICATION WAS FILED AND REASONS FOR DISAPPROVAL.
7. ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA?
a. IF NATURALIZED, GIVE DATE AND LOCATION WHERE NATURALIZATION PAPERS WERE ISSUED.
b. IF NOT A CITIZEN, GIVE CURRENT CITIZENSHIP STATUS.
8. HAVE YOU AS AN INDIVIDUAL OR IN CONNECTION WITH A PARTNERSHIP, FIRM, OR CORPORATION EVER BEEN CONNECTED
WITH A FEDERAL PERMIT OR APPROVED NOTICE TO MANUFACTURE, USE, STORE, RECTIFY, BOTTLE, DISTRIBUTE, SELL,
DEAL IN, IMPORT, OR TRANSPORT ALCOHOL, DENATURED SPIRITS, DISTILLED SPIRITS, BEER, WINES, OR TOBACCO
PRODUCTS?
IF THE ANSWER IS “YES,” GIVE THE FOLLOWING AS APPLICABLE:
a. PERMIT NUMBER, IF KNOWN
c. NAME AND ADDRESS UNDER WHICH PERMIT WAS ISSUED
b. PERIOD COVERED
d. IF DISCONTINUED, WHEN AND WHY?

e. IF REVOKED, WAS SETTLEMENT MADE OF CIVIL LIABILITIES
INCURRED THEREUNDER? IF “YES,” WHEN?
IF NO LIABILITIES, SO STATE.

9. HAVE YOU EVER BEEN OR ARE YOU NOW EMPLOYED BY ANY PERSON, FIRM, OR CORPORATION MANUFACTURING OR
EXPORTING TAX-EXEMPT TOBACCO PRODUCTS; PRODUCING, STORING, RECTIFYING, BOTTLING, SELLING, IMPORTING,
OR DEALING IN DISTILLED SPIRITS, WINES, BEER, ALCOHOL, OR DENATURED SPIRITS; USING OR DISTRIBUTING DENATURED SPIRITS; OR USING (OTHER THAN FOR PERSONAL USE) DISTILLED SPIRITS OR ALCOHOL?
IF THE ANSWER IS “YES,” GIVE THE FOLLOWING:
a. WHEN EMPLOYED
b. IN WHAT CAPACITY c. NAME AND ADDRESS OF PERSON, FIRM, OR CORPORATION

TTB F 5000.9 (02/2008)

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YES NO

10. EMPLOYMENT FOR PAST 10 YEARS
NAME AND ADDRESS OF EMPLOYER
(No., street, city, county, State, ZIP Code)
POSITION
(Include nature, periods, and addresses of self-employment)

PERIOD
FROM

TO

11. NAMES AND ADDRESSES (No., street, city, county, State, and ZIP Code) OF FIVE REFERENCES, INCLUDING AT LEAST ONE BANK REFERENCE, AS TO YOUR CHARACTER AND BUSINESS RESPONSIBILITY. (Do not include relatives or employers listed in item 10.)
NAME

RESIDENCE

BUSINESS NAME AND ADDRESS

BANK REFERENCE:

TELEPHONE NUMBER
CHARACTER/BUSINESS REFERENCE

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

TELEPHONE NUMBER

CHARACTER/BUSINESS REFERENCE

CHARACTER/BUSINESS REFERENCE

CHARACTER/BUSINESS REFERENCE

12. ARE YOU RATED BY ANY COMMERCIAL CREDIT REPORTING AGENCY?
YES

NO IF ANSWER IS “YES” GIVE NAME AND ADDRESS OF AGENCY AND DETAILS OF RATING.

13. RESIDENCES FOR PAST TEN YEARS (Give street address, city, county, State, and ZIP Code)
PERIOD
ADDRESS
FROM
TO

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14. INVESTMENTS
a. AMOUNT OF YOUR INVESTMENT IN THE BUSINESS TO DATE (If any)

$

b. SOURCE OF FUNDS INVESTED (e.g., personal savings, loans, etc.; give name and address of institution in which funds are on deposit, or
name and address of lender including account number, if applicable)

CERTIFICATION
Under the penalties of perjury, I declare that this statement, including the documents submitted in support thereof, has been examined by me and, to the
best of my knowledge and belief, is true, correct, and complete.
SIGNATURE OF APPLICANT

DATE

REMARKS ( Use space below or continue on a separate sheet if necessary.)

PRIVACY ACT STATEMENT
The following information is provided pursuant to Section 3 and 7(b) of the Privacy Act of 1974 (5 U.S.C. 552a(e)(3)):
1. AUTHORITY. Solicitation of this information is made pursuant to the following statutes: 26 U.S.C. 5171(b), 5271(b), 5356, 5401(a), 5502(b),
5511(3), and 5712, and 27 U.S.C. 204(c). Disclosure of this information by an applicant is mandatory if the applicant wishes to engage in any of the
businesses regulated pursuant to the above described statutes.
2. PURPOSE. To enable TTB to determine the eligibility, suitability, and/or qualifications of an applicant who proposes to engage in a business
regulated by TTB.
3. ROUTINE USES. The information will be used by TTB to make the determinations set forth in paragraph 2. In addition, the information may be disclosed to other Federal, State, foreign, and local law enforcement and regulatory agency personnel to verify information on the form where such disclosure is not prohibited by law. The information may further be disclosed to the Justice Department if it appears that the furnishing of false information may constitute a violation of Federal law. Finally, the information may be disclosed to members of the public in order to verify the information on
the form where such disclosure is not prohibited by law.
4. EFFECTS OF NOT SUPPLYING INFORMATION REQUESTED. Failure to provide complete information may prevent TTB from making an informed
judgment regarding the eligibility, suitability, and/or qualification of the applicant. This may result in either a delay in the approval of an application
or its disapproval.
5. DISCLOSURE OF SOCIAL SECURITY NUMBER. Disclosure of the individual social security number is voluntary. Pursuant to the statutes
above, TTB is authorized to solicit this information. The number may be used to verify the individual’s identity.
PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. The information collection is used by TTB to determine if an applicant is eligible
to receive an alcohol and a tobacco permit. The information is mandatory (26 U.S.C. 5712, 27 U.S.C. 204).
The estimated average burden associated with this collection of information is 2 hours per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the
Reports Management Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade Bureau, 1310 G Street, NW, Washington, DC 20220.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current, valid OMB
control number.

TTB F 5000.9 (02/2008)

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