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2. 
3. BEVERAGE OPERATOR'S LICENSE APPLICATION
5. First Name*
6. Middle Name
7. Last Name*
8. Former Name(s)
10. Address*
12. City*
13. State*
14. Zip Code*
16. Permanent Address, If Not Current
18. Telephone*
19. Email
21. Date of Birth*
22. Place of Birth*
24. Driver's License #*
25. State*

27. List ALL Addresses You Have Lived At Over The Past Five Years

29. Dates
30. Address
32. Dates
33. Address
35. Dates
36. Address
38. Dates
39. Address
41. Dates
42. Address
44. Have you completed a Beverage Server Training Course?*

    1. Yes
    2. No
45. If Yes, What Company?
46. Date
48. Do you currently have a Beverage Operator's License in another Municipality?*

    1. Yes
    2. No
49. If Yes, What Municipality issued the license?
51. Check One*

    1. 1 Year License - $20
    2. 2 Year License - $30
52. City of Whitewater Employing Establishment*

56. HAVE YOU EVER BEEN CHARGED WITH OR CONVICTED OF ANY CRIME, TRAFFIC VIOLATION, OR VIOLATION OF A MUNICIPAL ORDINANCE (Excluding parking tickets)? 
     

58. If Yes, please provide the following: (Addional paper provided if needed.)*

    1. Yes
    2. No
60. Date of Arrest
61. Arresting Agency
63. Offense
65. Date of Arrest
66. Arresting Agency
68. Offense
70. Date of Arrest
71. Arresting Agency
73. Offense

75. I CERTIFY THAT I HAVE ATTAINED THE AGE OF 18; AND I SPECIFICALLY STATE THAT I HAVE LISTED ABOVE INFORMATION ON ANY CHARGES OR CONVICTIONS RELATING TO ANY FELONY, MISDEMEANOR, MUNICIPAL CITATION, OR ANY OTHER OFFENSE; AND THAT I AM FAMILIAR WITH THE LAWS, ORDINANCES AND ALL PROVISIONS OF SAID LAWS, AND THAT ALL INFORMATION STATED ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

     

    FURTHER, I HEREBY AUTHORIZE A CRIMINAL HISTORY CHECK AND HEREBY CONSENT FOR THE CITY OF WHITEWATER TO CONDUCT A CRIMINAL HISTORY BACKGROUND CHECK THAT MAY INCLUDE PHOTOGRAPH(S) AND FINGERPRINTS.  I HEREBY ALSO RELEASE THE CITY OF WHITEWATER, AS WELL AS ANY OTHER MUNICIPAL, STATE OR FEDERAL LAW ENFORCEMENT AGENCIES, BOTH INDIVIDUALLY AND COLLECTIVELY, FROM ANY AND ALL LIABILITY FOR DAMAGES OF WHATEVER KIND WHICH MAY BE INCURRED BY ME, MY HEIRS, SUCCESSORS AND ASSIGNS DUE TO COMPLIANCE WITH SAID AUTHORIZATION AND RELEASE OF INFORMATION. I ALSO ACKNOWLEDGE THAT $7 OF THE FEE PAID IS TO COVER THE COST TO THE STATE FOR THE MANDATED BACKGROUND INVESTIGATION.

77. Signature*
78. Date*

82. Attach the Following Items:

84. A copy of your Driver’s License*
85. A copy of your Training Certificate
89. Received By
90. Date
91. Sent to PD
93. PD Approved
94. Denied
95. Date
Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field