Get IL IHF 2017-2024

IHF INDIVIDUAL HISTORY FORM FORM REQUIRED For any individual undergoing a background check in relation to a City of Chicago business license. INSTRUCTIONS Provide the information requested below. This form must be signed by the individual whose information is provided and A PHOTOCOPY OF CURRENT GOVERNMENT-ISSUED PHOTO ID MUST ALSO BE INCLUDED FOR THE INDIVIDUAL. PERSONAL INFORMATION PROVIDE THE FOLLOWING PERSONAL INFORMATION FIRST NAME MIDDLE NAME MAIDEN NAME IF APPLICABLE LAST NAME CURRENT RESIDENTIAL STREET ADDRESS SUITE/APT CITY HOME PHONE WORK PHONE MOBILE PHONE SSN OR ITIN PLACE OF BIRTH IN AGE HAIR COLOR ZIP CODE EMAIL ADDRESS DATE OF BIRTH / WEIGHT FT STATE - SUFFIX EYE COLOR JOB TITLE RELATIONSHIP TO APPLICANT SEX DRIVER S LICENSE OR STATE ID NUMBER LBS HAVE YOU EVER BEEN FINGERPRINTED FOR A CHICAGO BUSINESS LICENSE MARITAL HISTORY CURRENT MARITAL STATUS NO YES IF YES PROVIDE YEAR FINGERPRINTED SINGLE SPOUSE OR EX-SPOUSE FIRST NAME WIDOWED MARRIED DIVORCED IF MARRIED/DIVORCED PROVIDE SPOUSE/EX-SPOUSE NAME BELOW CURRENT LAST NAME MAIDEN NAME/MARRIED NAME NOTE IF YOU ARE APPLYING FOR A LIQUOR LICENSE AND YOU OWN 5 OR MORE INTEREST EITHER DIRECTLY OR INDIRECTLY IN THE APPLICANT ENTITY THEN YOUR CURRENT SPOUSE MUST COMPLETE A SPOUSAL AFFIDAVIT SPA FORM AND PROVIDE A PHOTOCOPY OF CURRENT GOVERNMENT ISSUED PHOTO ID. CRIMINAL HISTORY TYPE OF OFFENSE CONVICTION DATE EMPLOYMENT HISTORY PENALTY/SENTENCE JURISDICTION STATE COUNTY PROVIDE YOUR COMPLETE EMPLOYMENT HISTORY FOR THE PAST 5 YEARS INCLUDE AN ATTACHMENT IF NECESSARY EMPLOYER NAME MOST RECENT IMMEDIATE SUPERVISOR EMPLOYER S STREET ADDRESS SUITE EMPLOYER S PHONE TYPE OF WORK EMPLOYED FROM ACKNOWLEDGEMENT REVIEW THE FOLLOWING STATEMENT AND SIGN YOUR ACKNOWLEDGEMENT BELOW I hereby certify that the information supplied in this form is true and complete and hereby authorize the City of Chicago to make all necessary inquiries to verify its accuracy. A false statement of material fact made on this form may violate federal state and/or local law and may subject any person making such a statement to a range of civil and criminal penalties such as a period of incarceration fines and an award to the City of Chicago of up to three times any damages incurred* In addition persons who submit false information are subject to denial of the requested City action* PRINTED NAME OF APPLICANT SIGNATURE OF APPLICANT DATE X IndividualHistoryFormV-07-06-2017 CITY OF CHICAGO Department of Business Affairs and Consumer Protection Small Business Center 121 North LaSalle Street Room 800 Chicago IL 60602 312 74-GOBIZ 744-6249 www. CRIMINAL HISTORY TYPE OF OFFENSE CONVICTION DATE EMPLOYMENT HISTORY PENALTY/SENTENCE JURISDICTION STATE COUNTY PROVIDE YOUR COMPLETE EMPLOYMENT HISTORY FOR THE PAST 5 YEARS INCLUDE AN ATTACHMENT IF NECESSARY EMPLOYER NAME MOST RECENT IMMEDIATE SUPERVISOR EMPLOYER S STREET ADDRESS SUITE EMPLOYER S PHONE TYPE OF WORK EMPLOYED FROM ACKNOWLEDGEMENT REVIEW THE FOLLOWING STATEMENT AND SIGN YOUR ACKNOWLEDGEMENT BELOW I hereby certify that the information supplied in this form is true and complete and hereby authorize the City of Chicago to make all necessary inquiries to verify its accuracy. A false statement of material fact made on this form may violate federal state and/or local law and may subject any person making such a statement to a range of civil and criminal penalties such as a period of incarceration fines and an award to the City of Chicago of up to three times any damages incurred* In addition persons who submit false information are subject to denial of the requested City action* PRINTED NAME OF APPLICANT SIGNATURE OF APPLICANT DATE X IndividualHistoryFormV-07-06-2017 CITY OF CHICAGO Department of Business Affairs and Consumer Protection Small Business Center 121 North LaSalle Street Room 800 Chicago IL 60602 312 74-GOBIZ 744-6249 www. .