1. 1. Full name, business and residence addresses and telephone numbers, residence addresses for past five years, date of birth, place of birth, Social Security number, if the individual is willing to provide it, and two references; and

2. 2. An authorization for release of personal information, on a form prepared by the commission, signed by the individual and providing that he:

   1. a. Authorizes a review by, and full disclosure to, an agent of the Virginia State Police, of all records concerning the individual;
   2. b. Recognizes the information reviewed or disclosed may be used by the Commonwealth of Virginia, its employees, the commission, members, staff and agents to determine the signer's qualifications for a license; and
   3. c. Releases authorized providers and users of the information from any liability under state or federal data privacy statutes.

In an application for a license, the applicant shall include the following with respect to each individual identified as an applicant, partner, director, officer, other policymaker, or holder of a direct or indirect record or beneficial ownership interest or other voting interest or control of five percent or more in the applicant and each individual identified pursuant to subdivisions 2 and 3 of 11VAC10-20-110:

Statutory Authority

§ 59.1-369 of the Code of Virginia.

Historical Notes

Derived from VR662-01-02 § 2.16, Virginia Register Volume 6, Issue 10, eff. March 14, 1990.