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2. Business Name*
3. Business Phone Number*
4. Applicant Business Capacity or Position*
6. Applicant First Name*
7. Applicant Last Name*
8. Applicant Middle Initial*
9. Applicant Phone Number*
11. Applicant Driver's License*

    Include State Name if other than California

12. Applicant Place of Birth*
13. Applicant Social Security Number*
14. Applicant Date of Birth*
    Applicant Date of Birth
16. Applicant Age*
17. Applicant Race*
18. Applicant Height
19. Applicant Weight*
21. Applicant Hair Color*
22. Applicant Eye Color*
24. Applicant Address*
26. City
27. State
28. Zip Code
30. Email Address
32. Other Names Used

    This included Former or Maiden Names

33. Rohnert Park Business License Number*
34. CA Board of Equalization Seller's Permit Number*
36. Business Address*
38. City*
39. State*
40. Zip Code*
42. Have you every Had an ownership interest in a similar kind of business?

    1. Yes
    2. No
44. If Yes, Please Explain Fully
46. Have you ever been convicted of a crime?*

    1. Yes
    2. No

    Includes any crime as a result of an arrest, citation or criminal complaint as well as any arrests or citations presently pending deposition. (Felony, Misdemeanor, Infraction, County/Municipal Code Violence- Including an convictions expunged via 1203.4 PC, not including any common traffic citation offenses.

48. If yes, Please explain fully

50. I, under penalty of perjury, have answered all these questions completely and truthfully. I understand that any incompleteness, falsification or misrepresentation of any face may result in the denial of this application or revocation of any license issued. 

52. Signature*

    Type First and Last Name

53. Date*
    Date
54. Copy of Driver's License or State Issued ID*
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field