State of Arizona Department of Liquor Licenses and Control · 11. Tax Records A. Transaction Privilege Sales. Use and Severance Tax Return (copies) B. Income Tax Return - city, slate

•State of Arizona

Department of Liquor Licenses and Control

Created 09/09/2019 @ 03:55:23 PM

Local Governing Body Report

LICENSE

Number:Name:State:Issue Date:Original Issue Date:Location:

Mailing Address:

Phone:Alt. Phone:Email:

LA BOTANA LOKAPending

Type:

Expiration Date:

8449 E SPOUSE DRIVEPRESCOTT VALLEY, AZ 86314USA8449 E SPOUSE DRIVEPRESCOTT VALLEY, AZ 86314USA(928)759-0921(928)499-1121ROCIO.G.RAMIREZ1214@GMA IL. C 0 M

012 RESTAURANT

OWNER

Name: ROCIO GARCIAGender: FemaleCorrespondence Address: 8449 E SPOUSE DRIVE

PRESCOTT' VALLEY, AZ 86314USA

Phone: (928)499-1121Alt. Phone:Email: [email protected] OM

Page 1 4)1'2

APPLICATION INFORMATION

Application Number: 75925Application Type: New ApplicationCreated Date: 09/09/2019

QUESTIONS & ANSWERS

012 Restaurant

1) If you intend to operate the business while your application is pending you will need an interimpermit pursuant to A.R.S.§4-203.01. Would you like to apply for an Interim Permit?If yes, after completing this application, please go back to your Licensing screen, under New LicenseApplication choose "Interim Permit" from the drop -down window.

No2) Have you submitted a questionnaire? Each person listed must submit a questionnaire and mail in a

fingerprint card along with a $22. processing fee per card.Yes

5) Are you a tenant? (A person who holds the lease of a property; a lessee)YesA Document of type LEASE is required.

6) Is there a penalty if lease is not fulfilled?No

7) Are you a sub -tenant? (A person who holds a lease which was given to another person (tenant) for allor part of a property)

No8) Are you the owner?

No9) Are you a purchaser?

No10) Are you a management company?

No11) Is the Business located within the incorporated limits of the city or town of which it is located'?

Yes12) What is the total money borrowed for the business not including the lease?

Please list lenders/people owed money for the business.0

13) Have you provided a diagram of your premises'?Yes

14) Is there a drive through window on the premises?No

15) If there is a patio please indicate contiguous or non-contiguous within 30 feet.NONE

16) Is your licensed premises now closed due to construction, renovation or redesign or rebuild?No

17) Have you provided a Restaurant Operation Plan form?Yes

18) Have you provided a Records Required for Audit form?Yes

Page 2 of 2

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•09/04/2019 13: 41 92 058772 0011°) SFF"3 Lic, NA 4 THE UPS STORE 2458 PAGE 04/12

Arizona Department of Liquor Licenses and ControlBOO W Washington 5th Floor

Phoenix, AZ, 85001-2034www.raliquor,gov

(602) 542-5141

RESTAURANT OPERATION PLAN

I. Name of restaurant (101

.btbrta_,6c,ase print):

Lab 10;

2. List equipment below by Make, Model, and Capacity: (PROVIDEIHE POLLOWING !ISMS ONLY, NOATTACHMENTS) — in • I

DUX USE ONLY

_01 ..„_.Kre46-2_14 ,fc„ . , z.p _i _wkaj i

A' - . . . . . • . ,

Vti5Zdn5e.-. 7CALELACEDarda,\Ai WOO

_—Oven

4. . . . . . . • • • • • • • •

Freezer

Refrigerator......_ .tinelth1/401.- I 4 : PA, ( n_ejt13 C -.5C1--GP.Com 51nV z dratird-)024dSink

Dish Washing Facings

Food Preparation Counter,Ipi...ntionoCO nr) P 311 i l''‘) ?r) • A d

pu 1,./ ,.._016 92- tic q 72Other F(..._:9,..ty- CCCII ) 1-4-e, A F'51-1.(1.5=_Qa.Pava5 $

3. Attach a copy of your full menulacludinepdpel(ema moles: Breakfast. Lunch, Dinner, and Nonalcoholic beverages).

4. List the leallegsamody for

a_ Restaurant dining area of your premises;Q9_11.9.1k1O.Sitai1ia seating)

b. Bar area of your premises:

c. Total dining and bar seating capacity of your premises:

5_ What Type of dinnerware and utensils are utilized within your restaurant?

4/z1+

Li I

E l Reusable 0 Disposable N21 Both/

6. Oces your restaurant have a bar area that is distinct and separate from the dining area? 1:514-5 El No

(If yes, whqtrlerctentaq, alba public. Boor space does this area cove?)

7. What percentage of your public premises is used prim anly for restaurant dining?

(Da jnclude kitOent ber) hi -too tables. O f flame area.) Li 5 %EL.72,2o1s Pniretinf,

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B. Does your msta urent contain any slitnlektigatliQi1S- or any_Other entettainmentlaYES 0 NoCifvtkspetlfv_Vtflet tvoes andfww_rnartv (examples: 4-nts. 2 -Pool Tables, 1 -Vide Game, etc.)

9. Do you have live entertainment or dancing? 0 YES Cg No(If veg. NiiillAttiPe. and how,Pften8.5exa mp)e: DJ -2 x a week. Karate -2 x a month, Live 6and-1xa month, ere.)

10. Use space below to 1st how many employees for each position to fully staff your business.

I. 'c'T-Q_AJI hove read this a ppficktion and the Eontents and all statements true, correct and complete.

Position How many

Cooks

Bartenders

HosteSees

Managers. 1 . 1 0 1 •• •••••••

SON er3

Other(

Other(

Other(

X '• K134mature of NT)

LIMEMMISIN111111911011111

State of County or

NOTARY

fr4-) GAL—The foregoing instrument was acknowledged before me this

My Corn mitmion Expires on:Mite

day of Qtk-F-

Stanton* of N ary Public

2/, hereby declare that) am the APPUCANT fling this application.

Year

G/22:2018 Page 2o12

Indtwduelm requoIng ADA saccr,mmorlaharn, coftie,02) 542.9027,

09/04/2019 13:41 9287720500•

THE UPS STORE 2458 PAGE 0 7/ 1 2

Arizona Department of Liquor Licenses andControl

800 W Washington 5th FloorPhoenix, AZ 85007-2934

WWW.fizliquongov(602) 542-5141

RECORDS REQUIRED FOR AUDITApplies to Series 11 (Hotel/Motel IN/Restaurant) & aeries 12 (Restaurant) Only

MAKE A cOPY OF WOpggiaghtlAtip_MJIMMARLIKU 0

In the event of an audit, you will be asked to provide to the Department any documents necessary to determinecompliance with A.R.S. §4-205.02(G). Such documents requesied may include however, are not limited to:

1. AU Invoices and receipts for the purchase of food and spirituous liquor for the licensed premises.

2. A list of afi food and liquor vendors

3. The restaurant menu used during the audit period

4. A price list for alcoholic beverages during the audit period

5. Merit -up figures on food arid alcoholic products during the audit period

6. A recent. accurate inventory of food and liquor (taken within two weeks of the Audit Interview Appointment)

7. Monthly Inventory figures- beginning and ending figures for food and liquor

8. Chart of accounts (copy)

9. Financial Statements -Income Statements -Balance Sheets

10. General Ledger

A. Sales Jounals(Monthly SaleS Schedules

1) Daily sales Reports (to include the name of each waitress/waiter, bartender. etc. with sales for that day)

2) Daily Cash Register To pes -Journal Tapes end 2 -tapes

3) Dated Guest Checks

4) Coupons/Specials/Discounts

5) Any other evidence to support income from food and liquor sales

9. Cash Receipts/Disbursement Journals

) Daily aank Deposit Slips

2) Bank Statements and canceled checks

11. Tax Records

A. Transaction Privilege Sales. Use and Severance Tax Return (copies)

B. Income Tax Return - city, slate and federal (copies)

C. Any supporting books, records, schedules or documents used in preparation of tax returns

12 Payroll RecordsA_ Copies of all reports required by the State and Federal Government

B. Employee Log (A.R.S. §4-119)

C. Employee time cards (actual document used to sign in and out each work day)

D. Payroll records for all employees showing haws worked each week and hourly wages

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13. Off -site Coteririg Records (must be complete and separate from restaurant records)

A. AU documents which support the income derived from the sale of food off the license premises.

B. All documents which support purchases made for food to be sold off the icenSed premises.

C. All coupons/specials/discounts

The sophistication of record keeping Var ies from establishment to establishment Regardless of each licensee's accountingmethods, the amount of gross revenue derived from the sale of food and liquor must be substantially documented.

! VOCATION OF YOIJR_LIQIJOR LICENSE MAYoc_oFIFYOU_F_AJLEUQMFLY VATHA&L4-Z10162ARRA&S,4516_:MNial,

A.R.S. §4-210(A)?

The licensee fails to keep for two years and make available to the department upon reasonable request allinvoices, records, bills or other papers and documents relating to the ourchese, sale and delivery of spirituous Neel"end. In the case of a restaurant or hotel -motel licensee, at invoices, records, bits or other papers and documentsrelating tc the purchase, sale and delivery of feed.

A.R.S. §4-205.02(G)

For the pu-pose of this section:

1,"Restauranty means art establishment which datives at least forty percent (40%) of its gross revenue from the sale of food2."Gross 115v4inue " means the revenue derived from all safes of food and spirituous liquor on the licensed premises.regardless of whether the sales of spirituous liquor are made under a restaurant license issued pursuant to this section orunder any other license that hes been issued for the premises pursuant to this article. •

NOTARY

I, flPflm Fa warn* naCi_____C; O. e.A.Ck have read and understand at aspects of this statement

11- C2 C 1 1 ° aeeritroWd.-eeettrolelo-Person I Aerie

My commission expires on:

State of 4 / 1/41 County ofthip forb olfnvignuatit 1 WI ankna

of\NY

eme lt

T.orr

9 4120 1 5

MAKE A COPY OF1H i g a l l t z u c u t a n s B AEPITW1 RECO

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719 SEP 9 Lior, LIE, PM 4 05Arizona Department of Liquor Licenses and Control

800 W Washington 5th FloorPhoenix, AZ 85007-2934

www.azliquor.gov(602) 542-5141

QUESTIONNAIREA.R.S.§4-202, 4-210

Type or Print with Black Ink

The fees allowed by R19-1-102 will be charged for all dishonored checks. s y+ATTENTION APPLICANT: This is a legally binding document. Please type or print in black ink. An investigation of yourbackground will be conducted. Incomplete applications will not be accepted. False or misleading answers may result in thedenial or revocation of a license or permit and could result in criminal prosecution.

Attention local governments: Social security and birth date information is confidential. This information may be given to lawenforcement agencies for background checks only.

QUESTIONNAIRE IS TO BE COMPLETED BY EACH CONTROLLING PERSON, AGENT AND MANAGER BEING DISCLOSED TO THE DEPARTMENT. EACHPERSON COMPLETING THIS FORM MUST SUBMIT A BLUE OR BLACK LINED FINGERPRINT CARD ALONG WITH A $22 FEE. FINGERPRINTS MUST BE DONEBY A LAW ENFORCEMENT AGENCY OR BONA FIDE FINGERPRINT SERVICE. FOR AN ADDITIONAL $13 FEE, FINGERPRINTS MAY BE DONE AT THEDEPARTMENT OF LIQUOR WHEN ACCOMPANIED BY A COMPLETED APPLICATION.

Liquor License#: t - (3t1. Check theAppropriateBox Z Controlling Person EAgent DPremises Manager

(complete all questions except #12)

2. Name: GrAs-c-Last

1)\oc.ctFirst Middle

Birth Date.1111.111.111L(NOT a public record)

1 .3. Social Security Driver License#:11111111110.111 State: PFC120110.,4. Place of birth: D• \„LA J C c0 C)W °'• Height: .„..) Weight: ‘9 0 Eyes: f)r Hair: B r -

City Stat COUNTRY (not county)-•.)(\ t„

5. Name of current/most recent spouse: sCON(t7, " rneY\Birth Date:Last First Middle (NOT a public record)

6. Are you a bona fide resident of Arizona? N c s a l o If yes, what is your date of residency:

7. Daytime telephone number:(97_5)L SZJ E-mail address: (06C9. (be) Vi(1)(3etx,\• GolY‘8. Business Name: L a , e-)okary,..Loy-o„ Business Phone: Cligi/ 7 5 61/0911

3L L•

tC\. spo,..t. Dr. ("0-tsGANAeLk Rz. \ 10,Qa,Q0\-t g(03(1-1

Street (do not use PO Box) City tate County Zip9. Business Location Address:

10. List your employment or type of business during the past five (5) years. If unemployed, retired, or student, list residence address.FROM

Month/YearTO

Month/YearDESCRIBE POSITION OR BUSINESS EMPLOYERS NAME OR NAME OF BUSINESS

(Street Address, City, State & Zip)

(ofA)j<is CURRENT -keS"\-- • 0 ...Y:r("\_Qt.' ,"\ L—t),L , inACLif\O. Le ILA, l'6LkL-k•CtE

.‹z75,4 3 j 4 --,oe(-6\\ \) ( c)

0 2 -,l'Ar6 Q-)1.1 UtaA4 QA,N\ R c rtt, 1Q0( •(=CQ,-(-1. a l c cz 3 )q,D ,

(ATTACH ADDITIONAL SHEET IF NECESSARY)

rtr i tati ti . Page 1 of 2Individuals requiring ADA accommodations please call (602)542-2999

111009/04/2019 13:41 9287720500 THE UPS STORE 2453

'19PAGE 03/12

SEP 9 LIT. Lic.

Miens De partmern of Liquor Licenses and Control800W Washington 50 Floor

Phoenix, AZ 85007-2934www.aix5iquor.gov

(502) 542-5141

QUESTIONNAIREA.R_S_§4-202. 4-210

Type or Print with East Ink

The fees down qy gi9-1-102,41 be oharggs fOr all r a s t h oATTEffRON APPUCAE: Ibis Is a legally binding document. Please type or print In pink_ ink. An investigation of yourbackground wis be conducted. Incomplete applications will not be accepted. False or misleading answers may result in thedenial or revocation of a license or permit and could result in criminal Enna eutiOn

Atterkilogia_ciatCIOVenroniterts:Sociat security and birth date information is conOd antler. This information may be given to lawenforcement agencies for background_checks only.

QUESTIONNAIRE Is TO BE coraPLEIED TIT EACH CONTROLLING riaisbis, AGENT AND MANAGER BEING DTICLOSED TO THE oEp-WtrISENT. EACHPERSON COmPLEriNG THIS FORM MUST SUBMIT A iLKSalitAgfang FINGERPRINT CARD ALONG WITH A 622 fEE. FINGERPRINTS MUST BE DONEBY A LAW ENFORCEMENT AGENCY OR BONA FOE RNGERPRve SERVICE FOR AN ADDITIONAL Sla RE, FINGERPRINTS MAY SE DONE Al THEDEPARTMENT OF LIQUOR WHEN ACCOMPANIED BY A COMPLETES) APPLICATION.

1. Check theAppropriateBox

2. Name:

Liquor License#:

**airing Person EAgent CDPremises Managerjcontplate all quesdons except 02)

pax I mate retard]A

3, Social Security 0: Driver Licens kjx,"11111111110111.- -- - State:_ _ •

4. Place of bir th, vtitle cotedrav

Height %---# Weight (1.0 Eyes: i3,1( Heir r. . . . .

JjL '6Ann't —RQ LO Birth Date:

5. Name of current/most recant spouse:

6. Are you a bona fide resident of Arizona?

7. Daytime teleo bione

8. Business Nettle:

0 ,10

Z.1)451 . L-01%.-9

9. Business Lo cat on Address: 3r i . e m k a U. ., 1

a

UcthcLt

f riot ago sex )

10. List your employment or type of business durino t

Birth Date: I *per warn)moos I-NOT • patgle warn)

If yes, what is your date of residency:

E-mail address: (00.0 - 9. TCIVVIArei Lit ti 91 ro, - 6 4 •cor-_

trueness HilorK: k bq,),I/ • I

\ iirs1/40

1 FROM• . i •at.. _ s

I

10Nan*1Y ear

—DESCRIBE POSITTON OR BUSINESS

_ _EMPLOYERS. MANE OR. NAME OF WITNESS

Ciet. ItOsAZIP)f l y-- -

. . f. .4.--S.1-7

- - t . . f .• td 1P: I I f likkma. _a ll a—kd 1:-..N6C0.-. f...

,ib

1 ),p S, _ g . ,4.11111111ri n

L-C7 A " i-•-••••-•••-•....•••••-• ------------ -------------",- w - 4....---- ..1%.5p ...g...'q_C.i. - - - 4 t els & . .

............„.._ ............_ . _

I / I I /201

(ATTACH AMMON& SHEET FF NECESSARY)

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/ I I 011. Provide your residence address informa1 ion for the last five (5) years: A.R.S. ,S4 -202(D)FROM

Month/YearTO

Month/Year RESIDENTIAL Street Address,.. .

CURRENT1 ,

S \ r---4 )\ I s a l A ej --c,--- -1 - 1(1Tht e --k . s r----( \ ( ,:), V i?-s 6

01[alti, - 't 1 ; ,C16I

Lrl LP 1 S,

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(ATTACH ADDITIONAL SHEET IF NECESSARY)

12. As a Controlling Person or Agent, will you be physically present and operating the licensed premises?If you answered YES, then answer #13 below. If NO, skip to #14.

13. Have you attended a DLLC approved Basic & Management Liquor Law Training Course within the past 3years?

14. Have you been cited, arrested, indicted, convicted, or summoned into court for violation of ANY criminallaw or ordinance, regardless of the disposition, even if dismissed or expunged, within the past five (5) years?

IrKies :No

Eiyesa,0

nYes1-71No

15. Are there ANY administrative law citations, compliance actions or consents, criminal arrests, indictments or EYesE/Nosummonses pending against you? (Do not include civil traffic tickets.) A.R.S.§4-202,4-210

16. Has anyone EVER obtained a judgement against you the subject of which involved fraud or misrepresentation? FlYes[jqo

17. Have you had a liquor application or license rejected, denied, revoked or suspended in or outside of Arizonawithin the last five years? A.R.S.§4-202(D)

18. Has an entity in which you are or have been a controlling person had an application or license rejected,denied, revoked or suspended in or outside of Arizona within the last five years? A.R.S.§4-202(D)

Efresao

Tfres o

If you answered "YES" to any Question 14 through 18 YOU MUST attach a signed statement.Give complete details including dates, agencies involved and dispositions.

CHANGES TO QUESTIONS 14-18 MAY NOT BE ACCEPTED

NOTARY

I (Print Full Name) C 0 4 ( 1) OS Ot VX,\Y\A \ i c C hereby declare that I am the Agent/ Controlling Person /Premises Manager filing this application. I have read this document and verify the contents and all statements are true,correct and complete, to the best of my knowledge.

Signature: % c \o c "-L -\ (ACA --t-:-Of\1\ \ ‘ ' e -E State of

My C4p uraLs4ipliE_ApjLes,oz _

i ..... tam..

1, . MARIA A SitWotssyPvblSc;VA

- ) Yawned CountyQ s My Commission Bones*A, ,i t Dsesmber 20, 2019emir

C ounty of Cfr1)---1- c) C--''-'The foregding instrument was acknoWiedgedi before me this

-4v f

b Day ofDay r\ Mobi Year

L. %01),Signature of Notary

The Licensee has authorized the person named on this questionnaire to act as manager for the above License.

PRINT NAME: SIGNATURE:

4,1411111, Page 2 of 2Individuals requiring ADA accommodations please call (602)542-2999

• •State of Arizona

Department of Liquor Licenses and Control800 W. Washington 5th Floor

Phoenix, AZ 85007(602) 542-5141

ARIZONA STATEMENT OF CITIZENSHIPOR ALIEN STATUS FOR STATE PUBLIC BENEFITS

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Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621,provides that, with certain exceptions, only United States citizens, United States non -citizen nationals, non-exempt "qualifiedaliens" (and sometimes only particular categories of qualified aliens), nonimmigrant, and certain aliens paroled into theUnited States are eligible to receive state, or local public benefits. With certain exceptions, a professional license andcommercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation tothe license agency that satisfactorily demonstrates the applicant's presence in the United States is authorized under federallaw.

Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals must alsocomplete Section III.

Submit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S.National Status, or Alien Status" with your application for license or renewal. If the document you submit does not contain aphotograph, you must also provide a government issued document that contains your photograph. You must submitsupporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your currentlegal name.

SECTION I - APPLICANT INFORMATION

INDIVIDUAL OWNER/AGENT NAME (Print or type) 0 C00 cCACt

SECTION ll - CITIZENSHIP OR NATIONAL STATUS DECLARATION

Are you a citizen or national of the United States?

If Yes, indicate place of birth:

t(Yes No

City 00Y CAI State (or equivalent) OW Q Country or Territoryi

If you answered Yes, 1) Attach a legible copy of a document from the attached list.

2) Name of document:Go to Section IV.

iaLcsch-t*

If you answered No, you must complete Section III and IV.

9/17/2018 Page 1 of 3Individuals requiring ADA accommodations please call (602)542-9027

4110SEC ION III — ALIEN STATUS DECLARATION

To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status bychecking the appropriate box. Attach a legible copy of a document from the attached list or other document asevidence of your status.

Name of document provided

Qualified Alien Status (8 U.S.C. §§ 1621(a)(1),-1641(b) and (c))

1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)

IT 2. An alien who is granted asylum under Section 208 of the INA.

3. A refugee admitted to the United States under Section 207 of the INA.

4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.

5. An alien whose deportation is being withheld under Section 243(h) of the INA.

6. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1,1980.

7 7. An alien who is a Cuban/Haitian entrant.

_18. An alien who has, or whose child or child's parent is a "battered alien" or an alien subject to extreme cruelty inthe United States.

Nonimmigrant Status (8 U.S.C. § 1621(a)(2))

F---1 9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.0 § 1101 et seq.] Non immigrants are personswho have temporary status for a specific purpose. See 8 U.S.0 § 1101(a)(15).

Alien Paroled into the United States for Less Than One Year (8 U.S.C. § 1621(a)(3))

10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA

Other Persons (8 U.S.0 § 1621(c)(2)(A) and (C)

7 11. A nonimmigrant whose visa for entry is related to employment in the United States, or

12. A citizen of a freely associated state, if section 141 of the applicable compact of free association approved inPublic Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States include the Republicof the Marshall Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 etseq.];

1713. Ai foreign national not physically present in the United States.

Otherwise Lawfully Present

14. A person not described in categories 1-13 who is otherwise lawfully present in the United States.

PLEASE NOTE: The federal Personal Responsibility and Work Opportunity Reconciliation Actmay make persons who fall into this category ineligible for licensure. See 8 U.S.C. § 1621(a).

9/17/2018 Page 2 of 3Individuals requiring ADA accommodations please call (602)542-9027

SECTION IV - DECLARATION

All applicants must complete this section.I declare under penalty of perjury under the laws of the state of Arizona that the answers and evidence I have given aretrue and correct to the best of my knowledge.

\o (00AOa avvdecIndividual Owner/Agent Printed Name

T \ C \ Gpcxc 01/40. C4cAvWc ec_Individual Owner/Agent Signature Today's Dale

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS

You must submit supporting legal documentation (i.e. marriage certificate) if thename on your evidence is not the same as your current legal name.

Evidence showing authorized presence in the United State includes the following:

1. An Arizona driver license issued after 1996 or an Arizona non -operating identification card.

2. A driver license issued by a state that verifies lawful presence in the United States.

3. A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia,

Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917),

American Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Mariana Islands

local time)

4. A United States certificate of birth abroad.

5. A Ured States passport. ***Passport must be signed"""

6. A foreign passport with a United States visa.

7. An 1-94 form with a photograph.

8. A United States citizenship and immigration services employment authorization document or refugee travel

document.

9. A United States certificate of naturalization.

10. A United States certificate of citizenship.

11. A tribal certificate of Indian blood.

12. A tribal or bureau of Indian affairs affidavit of birth.

13. Any other license that is issued by the federal government, any other state government, an agency of this

state or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing

the license.

9/17/2018 Page 3 of 3Individuals requiring ADA accommodations please call (602)542-9027

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• •Certificate # AZM-02788 I19 co--, 9 L

W, Lic. Frs. 4 .05

Certificate of CompletionFor

Title 4 MANAGEMENT Liquor Law TrainingA Certificate of Completion must be on a form provided by the Arizona Department of Liquor. Certificates are completed by a state-

approved training provider and, when issued, the Certificate is signed by the course participant.

Basic Title 4 training is a prerequisite for MANAGEMENT Title 4 training. A valid Certificate of Completion for BASIC Title 4 training must be on fileat the Department of Liquor and satisfactory completion of a State -approved BASIC Title 4 course must be verified by the training provider priorto issuing a Certificate of Completion for MANAGEMENT Title 4 training.

A replacement Certificate of Completion for Title 4 training must be available through the training provider for two years after the trainingcompletion date.

Student Information

Rocio GarciaFull Name (please print)

, \ C a INC CAe kSignature

06/22/2019 06/22/2022Training Completion Date Certificate Expiration Date

(three years from completion date)

Training Provider Information

360training.com Inc.Company Name

6801 N Capital of Texas Hwy, Bldg I, Suite 250, Austin, TX 78731Mailing Address

(877) 881-2235Daytime Contact Phone Number

Samantha Montalbano , certify that the above named individual did successfully completeInstructor Name (please print)

Title 4 MANAGEMENT Training in accordance with A.R.S. §4-112(G)(2) and Arizona Administrative Code(A.A.C.)R19-1-103 using training course content and materials approved by the Arizona Department of LiquorLicenses and Control. I understand that misuse of this Certificate of Completion can result in the revocation ofState -approval for the Title 4 Training Provider named in this section as provided by A.A.C. R19 -1-103(E) and (F).

06/22/2019Instructor Signdfture Day Mo Year

Persons required to complete BASIC 8, MANAGEMENT Title 4 training: 1) owner(s) actively involved in the daily business operations of a liquor-licensed business of a series listed below

12) licensees, agents and managers actively involved in the daily businessoperations of a liquor -licensed business of a series listed below

In -state Microbrewery (series 3)Conveyance (series 8)Restaurant (series 12)

Government (series 5)Liquor Store (series 9)In -state Farm Winery (series 13)

Bar (series 6)Private Club (series 14)

Beer & Wine Bar (series 7)Hotel/Motel w/restaurant (series 11)Beer & Wine Store (series 10)

Liquor license applications (initial and renewal) are not complete until valid Certificates of Completion for all required persons have beensubmitted to the Department of Liquor,The questionnaire (which designates a manager to a location) and the agent change form (which assigns a new agent to active liquorlicenses) are not complete until valid Certificates of Completion for all required persons have been submitted to the Department of Liquor.

July 11,2013

09/04/2019 13:41 9287720500• •

THE UPS STORE 2458 PAGE 12/12

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