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

OMB No. 1513-0002 (03/31/2012)
DATE

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)

PERSONNEL QUESTIONNAIRE - ALCOHOL AND TOBACCO PRODUCTS
I. SUPPLEMENTAL TO APPLICATION FOR PERMIT FILED BY:
(Identify the business with application for permit, Brewer's Notice or Application to Operate Wine Premises on file with TTB.)
1.

Business Name (Name of Owner, Partners, Corporation, 3.
LLC, etc.)

2.

Business Telephone Number
(

)

-

Business Mailing Address (No., Street, City, State, and ZIP Code or
PO Box)

EXT

II. INDIVIDUAL RELATED TO APPLICATION FILED BY BUSINESS IDENTIFIED IN SECTION I
(Related individuals may be Owners, Officers, Directors, Members, Partners, etc. with connection to the business identified in Section I)
4.

11. Your Home Telephone
Number

Your Full Name (Do not use initials)

(
5.

Name You Usually Use

-

(

)

-

13. Your Work Telephone Number
(

6.

)

12. Your Cellular/Mobile
Telephone Number

Have you ever been known by ANY other name?
(Select Yes or No. If yes, provide nicknames, aliases)

)

Extension

-

14. Your Place of Birth (City, State, Country)

Yes
No
7.

15. Your Birth Date

If you are a married woman, give your full maiden name(s) &
date(s) of marriage

17. Your Gender

16. Your Social Security No.

18. Your Height

19. Your Weight

MALE
FEMALE
20. Your Hair Color
8.

FT.

IN.

LBS.

21. Your Eye Color

Your Legal Residence (No., Street, City, State, and ZIP Code)
22. Your Father's Full Name

23. Your Mother's Full Maiden Name
9.

Your Work Address (No., Street, City, State, and ZIP Code)

Check if
Same as:

24. Your Position or Title With the Business Listed In Section I.

Item 3
Item 8

10. Your Email Address ([email protected])

TTB F 5000.9 (08/2010)

25. Description of Your Duties or Relationship to the Business
Listed in Section I.

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OMB No. 1513-0002 (03/31/2012)

III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY
(TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful.
Attach a separate sheet of paper if necessary to provide further explanations.)
If the answer to any question in this section is “Yes,” give full details in the area provided, under remarks or on a separate sheet, taking care
to number the responses to correspond with the question. Convictions, arrests, or charges for minor traffic violations need not be reported.
26. Have you ever been arrested for any violation of any FEDERAL or STATE law related to LIQUOR or TOBACCO PRODUCTS ?
27. Have you ever been arrested for violation of any other FEDERAL or STATE law?
28. Have you ever been convicted of any FELONY or MISDEMEANOR under FEDERAL or STATE law?
29. 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?

Yes
No
Yes
No
Yes
No
Yes
No

30. 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 Yes
filed by you or any firm or corporation of which you were proprietor or a partner, officer, director, principal stockholder, or
No
responsible employee?
30a. If your answer is “Yes,” provide the name under which the application was filed and the reason(s) for disapproval.

Yes

31. Are you a United States of America citizen?

No

31a. If you are a naturalized citizen, provide the date and location
where your naturalization papers were issued.

31b. If you are not a citizen, give your current citizenship
status.

32. Have you as an individual or in connection with a partnership, LLC., 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?

Yes
No

32a. If your answer is “Yes,” provide the following, as applicable:
i.

Registry or Permit Number, if known

iv.

Name and Address under which the approved permit/notice was issued

ii. Period covered

iii. If discontinued, when and why?

v. If revoked, was settlement made of CIVIL liabilities incurred thereunder? Yes
If “Yes,” when?
No

If there were no liabilities, make a statement to that affect:

TTB F 5000.9 (08/2010)

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OMB No. 1513-0002 (03/31/2012)

III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY continued
(TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful.
Attach a separate sheet of paper if necessary to provide further explanations.)
33.Have you ever been or are you now employed by any person, firm, LLC., or corporation manufacturing or exporting tax-exempt
Yes
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) No
DISTILLED SPIRITS or ALCOHOL?
33a. If your answer is “Yes,” provide the following information:
i.

Period When Employed

iii.

Name and Address of Person, Firm, LLC., or Corporation

ii. In What Capacity/Position

34. Your Employment History for the Past 10 Years (Include nature, periods, and addresses of self-employment)
34a.
Period
(From/ To - MM/YYYY)

34c.
Name and Address of Employer
(No., street, city, county, State, ZIP Code)

34b.
Position Held

Present

To:

From:

To:

From:

To:

From:

To:

From:

To:
From:
35. Are you rated by any commercial credit reporting agency?
Yes

No If your answer is “Yes” provide the name and address of the commercial credit reporting agency and details of your
rating.

TTB F 5000.9 (08/2010)

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OMB No. 1513-0002 (03/31/2012)

III. INDIVIDUAL'S ARREST, CRIMINAL AND BUSINESS BACKGROUND HISTORY continued
(TTB will conduct a background check on the individual listed above. Make sure answers in this document are completely truthful.
Attach a separate sheet of paper if necessary to provide further explanations.)
36. Your Residences for Past Ten (10)Years (Provide the Street Address, City, County, State, and ZIP Code)
36a.
Period
(From/ To - MM/YYYY)
To:

36b.
Residence Address

Present

From:
To:
From:
To:
From:
To:
From:
37. Your Investments
37a. Amount of Your Investment in the Business to Date (If any)

$

37b. Source of the Funds You 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)

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

TTB F 5000.9 (08/2010)

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OMB No. 1513-0002 (03/31/2012)

IV. REFERENCES
(Provide 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 34.)

39. Business and Character References
39a.
Person's Name
i.

39b.
Residence

39c.
Business Name and Address

Bank Reference Name

Business Telephone Number
(

)

-

Ext.

ii. Character/Business Reference Name

Business Telephone Number

Home or Mobile Telephone Number

(

(

)

-

Ext.

)

-

iii. Character/Business Reference Name

Business Telephone Number

Home or Mobile Telephone Number

(

(

)

-

Ext.

)

-

iv. Character/Business Reference Name

Business Telephone Number

Home or Mobile Telephone Number

(

(

)

-

Ext.

)

-

v. Character/Business Reference Name

Business Telephone Number

Home or Mobile Telephone Number

(

(

)

-

Ext.

)

-

V. CERTIFICATION
(The individual named in Item I should sign below.)
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.
40. Applicant Signature

TTB F 5000.9 (08/2010)

41. Date

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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 (08/2010)

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