[City of Sacramento] Personal Disclosure Statement

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

Record Number

Business Name

Other names you have used

Phone Number

Email Address

How many years have you lived in CA?

Driver License Number

Date of Birth

(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?

Yes

What type of permit?

Have you ever had a permit or license revoked or denied, within this City?

Yes

Please explain why the permit or license was revoked or denied:

Have you ever had your driver license suspended or revoked?

Yes

Why was your 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?

Yes I am

No I am not

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).

Yes

Offense Charged With:

City that you were Charged in:

Date of Arrest

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

Applicant Signature

First Name

Last Name

Choose how to sign

Draw Type

I HEREBY CERTIFY UNDER THE PENALTY OF PERJURY THAT THE ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND I UNDERSTAND AND AGREE THAT ANY FALSE OR MISLEADING ANSWER WILL RESULT IN THE DENIAL OR REVOCATION OF ANY PERMIT. I UNDERSTAND THAT VERIFICATION OF THE ACCURACY OF THE PRECEDING INFORMATION IS A MATTER OF PUBLIC RECORD AND MAY BE MADE AVAILABLE TO INTERESTED PARTIES UPON REQUEST