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Form Section 1
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PERSONAL DISCLOSURE STATEMENT
BUSINESS OWNER, MEMBER, PARTNER
CORPORATE SHAREHOLDER, OFFICER, DIRECTOR

Each person with a ten percent or greater financial interest in the business must complete this form*
ATTENTION: 
The permit may be denied, suspended, or revoked if you make a false statement in this application, or for reasons specified in Sacramento City Code.


General Information

Full Name
Current Residence Address
Date of Birth
Date Picker

(click on month/year to change larger units of time in date picker)


City Information

Do you currently hold a valid city of Sacramento permit?
Have you ever had a permit or license revoked or denied, within this City?
Have you ever had your driver license suspended or revoked?
Are you familiar with the ordinances of the City of Sacramento and the laws of the State of California pertaining to the application?
Have you ever been convicted of crime: (Include convictions by Verdict, Plea of Guilty, Plea of no Contest, any fines paid, Diversion Programs completed, DUI).
Date of Arrest
Date Picker

(click on month/year to change larger units of time in date picker)


Applicant Signature