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OMB No. 1513-
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
PERSONNEL QUESTIONNAIRE ---
ALCOHOL AND TOBACCO PRODUCTS
DATE
I. THIS FORM IS FILED AS A SUPPLEMENT TO APPLICATION FILED BY:
(Identify the business that has submitted an application for a TTB permit or has submitted a Brewer’s Notice or other request for TTB approval to operate.)
- Name of Business 3. Premises (Physical) Address (No., Street, City, State, and Zip Code)
- Primary Business Telephone Number
( ) - EXT
II. INFORMATION FOR THE INDIVIDUAL RELATED TO THE APPLICATION FILED BY THE BUSINESS IN SECTION I
(Related individuals may be owners, officers, directors, members, partners, etc., with a connection to the business identified in Section I.)
- First Name, Middle Name, Last Name 8. Your Email Address
- Have you ever been known by ANY other name? (Select Yes or No. If yes, provide other names used including nicknames, aliases, married name, maiden name, and include the date of any legal name change.)
Yes □
No
- Your Primary Personal Telephone Number
- Your Place of Birth (City, State, Country)
- Your Birth Date 12. Your Social Security No.
- Your Legal Residence (No., Street, City, State, and ZIP Code)
- Your Gender
Check if the same as:
Item 3 □
Item 6 □
- Your Position or Title with the Business Listed in Section I.
□ MALE FEMALE
- Your Work Address (No., Street, City, State, and ZIP Code)
III. INDIVIDUAL’S ARREST, CRIMINAL, AND BUSINESS BACKGROUND HISTORY
(TTB will conduct a background check on the individual listed in Section II. Make sure answers in this document are completely truthful. If necessary, please use the additional space in Item 30 on the last page or attach a separate sheet of paper to provide further explanations, making sure to identify the question to which you are responding.) If the answer to any question in this section is “ Yes ,” please provide full details in the area provided, the additional space in Item 30 on the last page, 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.
- Have you ever been^ summoned for, arrested for, or charged with^ any violation of any FEDERAL or STATE law^ related to products regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobacco products, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or the Federal Alcohol Administration Act?
No □
- Have you ever been^ summoned for, arrested for, or charged with^ a FELONY violation of any other FEDERAL or^ STATE law?
Yes □
No □
- Have you been^ summoned for, arrested for, or charged with^ a MISDEMEANOR violation of any other FEDERAL^ or STATE law within the last ten (10) years?
Yes □
- Have you ever been convicted of any FELONY or MISDEMEANOR under FEDERAL or STATE law?
Yes □
No □
- Have you ever compromised or settled, by payment (including fines), stipulated suspension, surrender of permit,^ or otherwise any violation of FEDERAL law relating to products regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobacco products, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or any violation of the conditions of a permit or registration issued to you under the Federal Alcohol Administration Act or the Internal Revenue Code?
Yes □
No □
- Has disapproval ever been given to any application or notice of intention to distill, produce, brew, manufacture,^ use, store, rectify or blend, bottle, distribute, sell, or import products regulated by Chapter 51 (distilled spirits, wine, and beer) or 52 (tobacco products, processed tobacco, and cigarette papers and tubes) of the Internal Revenue Code or the Federal Alcohol Administration Act filed by you or any firm or corporation of which you were proprietor or a partner, officer, director, principal stockholder, or responsible employee?
Yes □
2 0a. If your answer is “ Yes ,” provide the name under which the application was filed and the reason(s) for disapproval.
No □
No □
Yes □
IV. ADDITIONAL INFORMATION OR EXPLANATION
- Please use this space to provide additional information or explanation, if necessary, taking care to number the responses
to correspond to the question (continue on separate sheet, if needed).
V. CERTIFICATION
(The individual named in Section II 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.
- Applicant Signature^25. Date
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.
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 a TTB permit or TTB approval to operate a regulated alcohol or tobacco business. The information is mandatory (26 U.S.C. 5171(d), 5181, 5271(b), 5356, 5401(a), 5502(b), 5511(3), and 5712; 27 U.S.C. 204).
The estimated average burden associated with this collection of information is 6 0 minutes per respondent, 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., Box 12, Washington, DC 20 005.
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.
PRIVACY ACT STATEMENT
AUTHORITY. Solicitation of this information is made pursuant to the following statutes: 26 U.S.C. 5171(d), 5181, 5271(b), 5356, 5401(a), 5502(b), 5511(3), and 5712, and 27 U.S.C. 204(c). Disclosure of this information is mandatory if the applicant wishes to receive a TTB permit or TTB approval to operate a regulated alcohol or tobacco busniess.
