| application must contain, but is not limited to, the following | information regarding the individual applicant and each officer, | director, partner or owner of interest in an association or | corporation, other than persons whose interest arises solely from | their ownership of publicly traded shares, applying for a | license: |
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| B.__Full current address and addresses for the prior 5 | years; |
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| C.__A record of previous issuances of, refusals to issue and | revocations of a license under this chapter; and |
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| D.__Answers to the following questions posed in | substantially the following form: |
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| (1)__"Is there a formal charging instrument now pending | against you in this or any other jurisdiction for a | crime that is punishable by imprisonment for one year | or more?"; |
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| (2)__"Is there a formal charging instrument now pending | against you in this or any other jurisdiction for a | juvenile offense that involves conduct that, if | committed by an adult, would be punishable by | imprisonment for one year or more?"; |
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| (3)__"Have you ever been convicted of a crime described | in subparagraph (1) or been adjudicated as having | committed a juvenile offense as described in | subparagraph (2)?"; |
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| (4)__"Are you a fugitive from justice?"; |
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| (5)__"Are you a drug abuser, drug addict or drug- | dependent person?"; |
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| (6)__"Have you been dishonorably discharged from the | military within the past 5 years?"; and |
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| (7)__"Are you an illegal alien?" |
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| | 2.__Signature as certification.__The applicant, by affixing | the applicant's signature to the application, certifies the | following: |
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| A.__That the statements made in the application and any | documents made a part of the application are true and | correct; |
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